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The role of the podiatrist in primary care

Podiatrists are the experts in all aspects of foot and lower limb structure, function and health. They are highly skilled health care professionals trained to diagnose, treat, rehabilitate and prevent disease and complications of the feet, ankles and lower limbs. They can prevent and manage foot problems, relieve pain, treat infection and support foot irregularities, to keep people of all ages mobile and active.

Podiatrists are ideally placed to use their expertise in primary care settings by developing and embedding services that extend the ability of GPs and primary care teams to provide a focus on prevention and early intervention.

Key skills of the podiatrist working in primary care

These include:

Diagnosis of new lower limb problems

Diagnosis, monitoring, and management of systemic disease, that manifests within the lower limb

Oversight of multi-disciplinary team management of the foot at risk of chronic disease complication or amputation

Oversight of personalised care planning for people living with long term conditions affecting the lower limb

Promotion of health and wellbeing, including signposting as appropriate, to support walking (physical activity), working, and wellbeing

Leadership of multi-disciplinary team prevention and management pathways, coordinated through primary care, primarily impacting the lower limb.

Download our flyer showing the role of podiatrists within primary care
First Contact Practitioners and Advanced Practioners - Roadmaps to practice

The First Contact Practitioners (FCP) and Advanced Practitioners in Primary Care: Roadmaps to Practice are supportive documents that describe an educational pathway from undergraduate to advanced clinical practice in primary care.

Template: FCP podiatry job description

This job description provides examples of how podiatrist roles have previously been recruited, working models and specialities, at Agenda for Change indicative Band 7. Download the job description

Download the Royal College of Podiatry's (RCPod's) policy position: Podiatrists as first point of contact practitioners
Next steps for integrating primary care: Fuller stocktake report
This is the final report, published 26 May 2022, of the stocktake undertaken by Dr Claire Fuller, Chief Executive-designate, Surrey Heartlands Integrated Care System and GP on integrated care, looking at what is working well, why it's working well and how we can accelerate the implementation of integrated primary care (incorporating the current four pillars of general practice, community pharmacy, dentistry and optometry) across systems. Download the report

Integrating additional roles into primary care networks

The Additional Roles Reimbursement Scheme (ARRS) was introduced in England in 2019 as a key part of the government's manifesto commitment to improve access to general practice. The aim of the scheme is to support the recruitment of 26,000 additional staff into general practice. The King's Fund take a look at the opportunities and challenges. Download Integrating additional roles into primary care networks

Explanation of Primary Care networks

Primary Care Networks build on existing primary care services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care for people close to home. Clinicians describe this as a change from reactively providing appointments to proactively caring for the people and communities they serve. Find out more

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The role of the podiatrist in primary care Podiatrists are the experts in all aspects of foot and lower limb structure, function and health. They are highly skilled health care professionals trained to diagnose, treat, rehabilitate and prevent disease and complications of the feet, ankles and lower limbs.

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Dietitians FCP roadmap

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The information below covers the most common areas that dietitians support within primary care

Frailty and malnutrition

Dietitians can reduce frailty and the risk associated with it by managing malnutrition - ensuring those at risk of malnutrition have an appropriate dietetic intervention. Dietitians in primary care can play a vital role in the prevention of frailty and malnutrition through early identification.
Our goals

early diagnosis

optimise nutrition management

reduce GP consultations

reduce referrals into secondary care

significant cost-saving strategies across the PCN

Following dietetic intervention, patients improved various outcome measures including; weight, BMI and handgrip strength.

Significant projected total annual cost savings of £15,379 were made by a dietitian reviewing oral nutritional supplements in just 27 patients in primary care.

People with diabetes

Dietitians can diagnose and manage pre-diabetes and diabetes in primary care. They are effective at improving diabetes control, achieving reductions in weight and waist circumference as well as improving diet quality. Dietitians provide early support and ongoing dietary and medication management of glycaemic control to reduce long term complications. Their expertise can support meeting the quality outcomes framework related to diabetes care.
Our goals

reduce or prevent the development of diabetes

reduce long term complications

support weight loss and improved quality of life for people with overweight or obesity

"Diabetes prevention programmes delivered by dietitians had greater weight loss outcomes"

People with overweight or obesity

Dietitians can support patients with a variety of weight management approaches to help reduce weight, manage co-morbidities associated with overweight or obesity, and improve quality of life. Their expertise can be shared across the multi-professional team to increase overall quality of care. Requirements of the Enhanced Service Specification for weight management can also be supported by the dietitian.

Over 60% of the population in England are overweight or obese. Over 3 million people in England have diabetes (90% have type 2).

Gastroenterology

Dietitians can diagnose and manage a range of nutrition and dietetic conditions including IBS. Dietitians can also support with the correct identification and diagnosis of suspected food allergies and intolerances.
Our goals

significant reduction in GP appointments

early diagnosis and treatment of conditions

improved quality of life for patients

Gastrointestinal conditions represent a significant proportion of GP consultations, with IBS being the most prevalent. Patients with undiagnosed IBS visit their GP ten times more frequently than matched patients.

Dietitians are able to reduce symptoms for 70% of patients with IBS and improve quality of life for 74% of patients.

Paediatrics

Dietitians can support paediatric populations with the diagnosis and management of a number of conditions relating to nutrition and dietetics including; faltering growth, constipation, gastro-oesophageal reflux, obesity, cow's milk protein allergy, food allergies and intolerances, food avoidance and fussy eating, as well as nutrient deficiencies such as iron deficiency. They can also provide expert advice and education for parents and for the multi-professional team.
Our goals

speed up diagnosis and treatment

support early identification of food allergies and intolerances

reduction of misdiagnosis and delayed diagnosis

improve patient care and outcomes

reduction in GP appointments

cost savings by ensuring appropriate prescribing of infant formula and specialist feeds

signpost for appropriate ongoing management

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Frailty and malnutrition Dietitians can reduce frailty and the risk associated with it by managing malnutrition - ensuring those at risk of malnutrition have an appropriate dietetic intervention. Dietitians in primary care can play a vital role in the prevention of frailty and malnutrition through early identification.

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NHS England and Health Education England have co-published this guidance document which describes the scope of practice of paramedics working in general practice. It includes information on education/development needs, supervision requirements and the differences between enhanced, first contact and advanced levels of practice.

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Roadmap FAQs 1. Do clinicians who have done an ACP Masters degree have to do the roadmap to work as an AP in primary care? “If you have undertaken an ACP MSc, it is likely that you will have met the capabilities for stage 1 and stage 3. You should map the learning outcomes of your MSc to the knowled…

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GP mythbuster 106: Primary care first contact practitioners (FCPs)

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This mythbuster describes the responsibilities for providers when recruiting and managing staff deployed in first contact practitioner (FCP) roles in primary care settings. This includes:

paramedics

first contact physiotherapists

dietitians

podiatrists

occupational therapists

Some of these roles will be funded through NHS England and NHS Improvement's Additional Roles Reimbursement Scheme, which includes requirements for recruiting, training and supervising. You should read a summary of these additional requirements alongside this document. This mythbuster applies both to staff employed using the reimbursement scheme and to other FCPs employed in primary care settings.

Background

As part of the NHS Long Term Plan, primary care networks (PCNs) and GPs were encouraged to build a team of people with diverse skills to:

support increased access for patients

reduce pressures on existing staff

improve the quality of care and services.

PCNs can receive funding for some of these roles from the Additional Roles Reimbursement Scheme. This can reimburse staff according to their skills, and capabilities and role, up to the maximum level of reimbursement, set out in the Network Contract Directed Enhanced Service (DES).

Allied health professionals (AHPs) can become first contact practitioners (FCPs) or advanced practitioners. Health Education England has developed a Roadmap for Practice for AHPs to show evidence of their capability for these roles. AHPs who have demonstrated these capabilities will be able to see and manage more clinically complex patients. They will also be able to work independently in primary care, within their scope of practice.

The Network Contract DES provides role descriptions for allied health professionals employed through the reimbursement scheme. Most AHPs will be working at a master's level clinically. Paramedics will have an option to be reimbursed at a lower level in a rotational scheme. These paramedics are not first contact practitioners.

Regulatory requirements

First contact practitioner roles in primary care can enhance patient care. They can help ensure the right person sees the patient at the right time. However, some of the staff deployed in these roles may be working in primary care for the first time and the setting may be unfamiliar.

The deployment of first contact practitioners through PCNs is a significant change for general practice providers. Providers will be accountable for staff who they may not employ directly, but who deliver regulated activity on their behalf.

All GPs responsible for delivering a regulated activity must register with CQC under the Health and Social Care Act. As part of the registration process, providers must show how they will meet the regulations.

The Health and Social Care Act 2008 (Regulated Activities) 2014 Regulations set out a provider's responsibilities. Our guidance for providers on meeting the regulations explains that providers are responsible for the staff they 'employ.' However, the meaning of 'employed' in the regulations is wider than staff employed on an employment contract. It means anyone who works for the provider, under their ongoing direction and control. The provider needs to be assured about the ' fitness ' of those persons. Recruitment by another party may provide some assurance. However, the registered provider should not assume these checks have been completed.

During an inspection, we will not review any regulated activity delivered by staff who are not employed or managed by a GP practice. This is because this activity is governed by a contract that the GP provider is not party to, and so is separately regulated.

Providers need to ensure that all the staff they manage have had the appropriate recruitment checks and are supervised. This is for all staff, irrespective of who holds the employment contract. This does not necessarily mean the provider must physically carry out or repeat all the processes. However, they do need to reasonably assure themselves that it has been done. For example, where a FCP is employed by a local NHS trust and provides services to a GP practice, it would be essential for the practice to ask for assurances. This could be a letter of confirmation, memorandum of understanding, or service level agreement from the trust. This needs to clarify the recruitment checks and responsibilities for day-to-day clinical supervision.

Primary care networks (as extensions of GP practices) determine how staff operate in general practice. GPs are required to be on the National Medical Performers List to provide general practice services. Other staff, such as nurses and allied health professionals, operate under the direct supervision of National Medical Performers.

Providers must ensure that staff are operating within the limits of their competency. They must also provide staff with appropriate supervision. The individual practice will allocate an appropriate senior member of the primary care team to provide day-to-day supervision of all clinical staff. Health Education England has published guidance for employers on workplace supervision for advanced clinical practice. The Health and Care Professions Council has also published guidance for AHPs on supervision standards.

First contact practitioners (FCPs) working in primary care are non-medical diagnostic clinicians. Training and education for FCPs is described in HEE's Roadmap for Practice. Stage 1 of the roadmap should be completed with a signed off portfolio of evidence before employment in primary care. Stage 2 is completed when working in primary care. This should be within six months for those in full-time equivalent FCP roles or longer if the employer and commissioner agree.

CQC will expect to see evidence or assurance that staff recruited into FCP roles have completed stage 1 of the roadmap. We will also expect arrangements for completion of stage 2 of the roadmap.

When we inspect

We regulate at the level of the individual registered provider. In the case of primary care networks, this will be the GP practices listed as the Core Network Practices in the Network DES.

We apply the regulations of the Health and Social Care Act when we review if the practice is:

We will look for evidence that providers have systems in place to ensure that:

staff are recruited appropriately

staff are operating within the limits of their capability, scope of practice and competency

they provide staff with appropriate information, support and supervision to enable them to carry out their role.

Fit and proper persons requirement

We will expect to see evidence that the provider has verified and is satisfied about safe recruitment practice. For example, asking the employer of a first contact practitioner for assurance and/or evidence that the necessary recruitment checks have been completed. This may include professional registration, Disclosure and Barring Service checks, references and qualifications.

This relates to Regulation 19: Fit and proper persons employed.

Governance systems

We will expect systems or processes to be in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients. This expectation is irrespective of who holds the employment contract.

This relates to Regulation 17: Good governance.

Suitably qualified, competent and experienced staff

We expect appropriate recruitment checks, professional registration and supervision for all staff. This expectation is irrespective of who holds the employment contract.

This relates to Regulation 18: Staffing.

Assessing staff skills, knowledge and experience

We will use our key lines of enquiry to assess how providers ensure staff have the skills, knowledge and experience to deliver effective care.

This will include but is not limited to:

safe recruitment

job plans

induction

policies and procedures

communication of alerts and guidance

clinical supervision

complaints and significant event arrangements.

We will check how the provider has assured themselves that staff are capable for the role. We will also check that the provider maintains this over time through ongoing supervision. This supervision may be carried out by any senior member of the team.

Further information

Frequently asked questions on the FCP/AP roadmaps (Health Education England)

Guidance on enabling the workforce (Health Education England)

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GP mythbuster 106: Primary care first contact practitioners (FCPs)

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This mythbuster describes the responsibilities for providers when recruiting and managing staff deployed in first contact practitioner (FCP) roles in primary care settings. This includes: paramedics first contact physiotherapists dietitians podiatrists occupational therapists Some of these roles will be funded through NHS England and NHS Improvement's Additional Roles Reimbursement Scheme, which includes requirements for recruiting, training and supervising.

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FCP's challenges and learning and development needs in response to managing fitness for work and sickness absence in primary care

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FCP's challenges and learning and development needs in response to managing fitness for work and sickness absence in primary care

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FCP's challenges and learning and development needs in response to managing fitness for work and sickness absence in primary care

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Abstract

Purpose: The UK's Departments of Health and Work and Pensions, within the White Paper Improving Lives: The Future of Work, Health and Disability, outlines the Legislation for extension of Fit Note sickness absence certification for those patients ill for more than 7 days in a row to other suitably qualified non-medical Allied Health Professionals (AHPs) along with a set of competencies to aid in its certification completion. The Statement of Fitness for Work (known as a 'Fit Note') was introduced in the UK in 2010 to allow clinicians to provide their patients with advice on fitness for work and to encourage patients to resume some work as soon as they have recovered sufficiently. Despite this, clinicians seem to not provide fitness advice on most Fit Notes and in 2016 the UK Government reported that the fit not was 'not fully achieving what it set out to do'. The role of certifying sickness absence in the UK has traditionally been conducted by General Practitioners in Primary Care settings, but this role increasingly is being carried out by AHPs who work within Occupational Health and Primary Care settings. More recently, the 2019 AHP Health and Work report was designed by a working group from the Chartered Society of Physiotherapy, Royal College of Occupational Therapy and College of Podiatry to provide information to the employee and employer on the functional impact of the patient's reported problem. The role of sickness absence certification and fitness for work advice is potentially amenable within the First Contact Practitioner (FCP) primary care model.
The main aim was to obtain consensus nationally for FCPs training and development needs and challenges in delivering OH focussed consults in primary care, including fitness for work recommendations and sickness absence certification.
Objectives: Conduct a Delphi study to gain consensus on the topic and explore the major parameters of the problem area (fitness for work and sickness absence) as perceived by FCP experts
Methods: The study used an online modified version of the Delphi Technique, to achieve FCP expert consensus.
Results: Study results to be finalised March 2021.
Conclusion(s): This research adds new evidence regarding the challenges and learning and development needs identified by a group of national FCPs working within primary care with regards to sickness absence certification and fitness for work advice.
Impact: OH experts will gain consensus on challenges faced and the learning and development items needed when delivering OH specific advice within primary care.  This study provides evidence to supplement and support frameworks on an important topic and suggests that FCPs are willing to take on this role with adequate support and training. It will be published through the peer review process and disseminated amongst key stakeholders including the CSP, PCNs, GP network and the wider NHS network.

Cite this

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title = "FCP's challenges and learning and development needs in response to managing fitness for work and sickness absence in primary care",

abstract = "Purpose: The UK{\textquoteright}s Departments of Health and Work and Pensions, within the White Paper Improving Lives: The Future of Work, Health and Disability, outlines the Legislation for extension of Fit Note sickness absence certification for those patients ill for more than 7 days in a row to other suitably qualified non-medical Allied Health Professionals (AHPs) along with a set of competencies to aid in its certification completion. The Statement of Fitness for Work (known as a {\textquoteleft}Fit Note{\textquoteright}) was introduced in the UK in 2010 to allow clinicians to provide their patients with advice on fitness for work and to encourage patients to resume some work as soon as they have recovered sufficiently. Despite this, clinicians seem to not provide fitness advice on most Fit Notes and in 2016 the UK Government reported that the fit not was {\textquoteleft}not fully achieving what it set out to do{\textquoteright}. The role of certifying sickness absence in the UK has traditionally been conducted by General Practitioners in Primary Care settings, but this role increasingly is being carried out by AHPs who work within Occupational Health and Primary Care settings. More recently, the 2019 AHP Health and Work report was designed by a working group from the Chartered Society of Physiotherapy, Royal College of Occupational Therapy and College of Podiatry to provide information to the employee and employer on the functional impact of the patient{\textquoteright}s reported problem. The role of sickness absence certification and fitness for work advice is potentially amenable within the First Contact Practitioner (FCP) primary care model. The main aim was to obtain consensus nationally for FCPs training and development needs and challenges in delivering OH focussed consults in primary care, including fitness for work recommendations and sickness absence certification. Objectives: Conduct a Delphi study to gain consensus on the topic and explore the major parameters of the problem area (fitness for work and sickness absence) as perceived by FCP experts  Methods: The study used an online modified version of the Delphi Technique, to achieve FCP expert consensus.  Results: Study results to be finalised March 2021.  Conclusion(s): This research adds new evidence regarding the challenges and learning and development needs identified by a group of national FCPs working within primary care with regards to sickness absence certification and fitness for work advice. Impact: OH experts will gain consensus on challenges faced and the learning and development items needed when delivering OH specific advice within primary care.  This study provides evidence to supplement and support frameworks on an important topic and suggests that FCPs are willing to take on this role with adequate support and training. It will be published through the peer review process and disseminated amongst key stakeholders including the CSP, PCNs, GP network and the wider NHS network. ",

keywords = "first contact practitioner, primary care, fitness for work",

author = "Cameron Black and Sivaramkumar Shanmugam and Heather Gray",

note = "Virtual Physiotherapy UK 2021, VPUK ; Conference date: 05-11-2021 Through 06-11-2021",

url = "https://www.csp.org.uk/professional-clinical/courses-events/physiotherapy-uk",

}

TY - CONF

T1 - FCP's challenges and learning and development needs in response to managing fitness for work and sickness absence in primary care

AU - Black, Cameron

AU - Shanmugam, Sivaramkumar

AU - Gray, Heather

PY - 2021/11/6

Y1 - 2021/11/6

N2 - Purpose: The UK's Departments of Health and Work and Pensions, within the White Paper Improving Lives: The Future of Work, Health and Disability, outlines the Legislation for extension of Fit Note sickness absence certification for those patients ill for more than 7 days in a row to other suitably qualified non-medical Allied Health Professionals (AHPs) along with a set of competencies to aid in its certification completion. The Statement of Fitness for Work (known as a 'Fit Note') was introduced in the UK in 2010 to allow clinicians to provide their patients with advice on fitness for work and to encourage patients to resume some work as soon as they have recovered sufficiently. Despite this, clinicians seem to not provide fitness advice on most Fit Notes and in 2016 the UK Government reported that the fit not was 'not fully achieving what it set out to do'. The role of certifying sickness absence in the UK has traditionally been conducted by General Practitioners in Primary Care settings, but this role increasingly is being carried out by AHPs who work within Occupational Health and Primary Care settings. More recently, the 2019 AHP Health and Work report was designed by a working group from the Chartered Society of Physiotherapy, Royal College of Occupational Therapy and College of Podiatry to provide information to the employee and employer on the functional impact of the patient's reported problem. The role of sickness absence certification and fitness for work advice is potentially amenable within the First Contact Practitioner (FCP) primary care model. The main aim was to obtain consensus nationally for FCPs training and development needs and challenges in delivering OH focussed consults in primary care, including fitness for work recommendations and sickness absence certification. Objectives: Conduct a Delphi study to gain consensus on the topic and explore the major parameters of the problem area (fitness for work and sickness absence) as perceived by FCP experts  Methods: The study used an online modified version of the Delphi Technique, to achieve FCP expert consensus.  Results: Study results to be finalised March 2021.  Conclusion(s): This research adds new evidence regarding the challenges and learning and development needs identified by a group of national FCPs working within primary care with regards to sickness absence certification and fitness for work advice. Impact: OH experts will gain consensus on challenges faced and the learning and development items needed when delivering OH specific advice within primary care.  This study provides evidence to supplement and support frameworks on an important topic and suggests that FCPs are willing to take on this role with adequate support and training. It will be published through the peer review process and disseminated amongst key stakeholders including the CSP, PCNs, GP network and the wider NHS network.

AB - Purpose: The UK's Departments of Health and Work and Pensions, within the White Paper Improving Lives: The Future of Work, Health and Disability, outlines the Legislation for extension of Fit Note sickness absence certification for those patients ill for more than 7 days in a row to other suitably qualified non-medical Allied Health Professionals (AHPs) along with a set of competencies to aid in its certification completion. The Statement of Fitness for Work (known as a 'Fit Note') was introduced in the UK in 2010 to allow clinicians to provide their patients with advice on fitness for work and to encourage patients to resume some work as soon as they have recovered sufficiently. Despite this, clinicians seem to not provide fitness advice on most Fit Notes and in 2016 the UK Government reported that the fit not was 'not fully achieving what it set out to do'. The role of certifying sickness absence in the UK has traditionally been conducted by General Practitioners in Primary Care settings, but this role increasingly is being carried out by AHPs who work within Occupational Health and Primary Care settings. More recently, the 2019 AHP Health and Work report was designed by a working group from the Chartered Society of Physiotherapy, Royal College of Occupational Therapy and College of Podiatry to provide information to the employee and employer on the functional impact of the patient's reported problem. The role of sickness absence certification and fitness for work advice is potentially amenable within the First Contact Practitioner (FCP) primary care model. The main aim was to obtain consensus nationally for FCPs training and development needs and challenges in delivering OH focussed consults in primary care, including fitness for work recommendations and sickness absence certification. Objectives: Conduct a Delphi study to gain consensus on the topic and explore the major parameters of the problem area (fitness for work and sickness absence) as perceived by FCP experts  Methods: The study used an online modified version of the Delphi Technique, to achieve FCP expert consensus.  Results: Study results to be finalised March 2021.  Conclusion(s): This research adds new evidence regarding the challenges and learning and development needs identified by a group of national FCPs working within primary care with regards to sickness absence certification and fitness for work advice. Impact: OH experts will gain consensus on challenges faced and the learning and development items needed when delivering OH specific advice within primary care.  This study provides evidence to supplement and support frameworks on an important topic and suggests that FCPs are willing to take on this role with adequate support and training. It will be published through the peer review process and disseminated amongst key stakeholders including the CSP, PCNs, GP network and the wider NHS network.

KW - first contact practitioner

KW - primary care

KW - fitness for work

M3 - Poster

T2 - Virtual Physiotherapy UK 2021

Y2 - 5 November 2021 through 6 November 2021

ER -

# data[].attributes.attachment_link.title
FCP's challenges and learning and development needs in response to managing fitness for work and sickness absence in primary care

# data[].attributes.attachment_link.description
Purpose: The UK's Departments of Health and Work and Pensions, within the White Paper Improving Lives: The Future of Work, Health and Disability, outlines the Legislation for extension of Fit Note sickness absence certification for those patients ill for more than 7 days in a row to other suitably qualified non-medical Allied Health Professionals (AHPs) along with a set of competencies to aid in its certification completion.

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https://www.england.nhs.uk/gp/expanding-our-workforce/first-contact-physiotherapists/

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Evaluation of the First Contact Physiotherapy (FCP) model of primary care: a qualitative insight

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Abstract

Objective

First Contact Physiotherapy (FCP) is a primary care model where expert musculoskeletal (MSK) physiotherapists undertake the first patient consultation, to enhance MSK-patient care and free-up GP capacity. The authors report the qualitative findings from the FCP National Evaluation (Phase 3) which evaluated the FCP model against pre-agreed success criteria.

Design and setting

A mixed-methods 24-month service evaluation involving FCP sites across England.

Methods

Data were collected at 2 time points, year 1 and year 2. Data were collected using individual interviews and focus groups, transcribed verbatim and analysed using a hybrid inductive and deductive thematic analysis. Participants were recruited from all stakeholder groups; patients, physiotherapists, general practitioners and administration staff.

Results

A total of 6 sites were recruited over both rounds of data collection demonstrating a wide range of service models. Thirty-nine participants were recruited including fourteen patients. All six qualitative success criteria were met. GPs' discourse reflected confidence in the FCP service and competence of the FCPs. Patient discourse reflected self-efficacy and confidence in self-management techniques and reported FCP as a positive experience. FCPs saw providing advice about work related issues as integral to their role and patient discourse reflected perceived benefit from the advice offered. Staff discourse reflected a positive experience of working with, and in, the FCP services.

Conclusion

Ahead of the planned scale-up of the FCP primary care model across the UK, this evaluation provides useful insights and recommendations to facilitate successful FCP implementation in terms of patient outcome and experience, and staff experience.

Keywords: Musculoskeletal, First Contact Physiotherapy, General practice, Primary care

Introduction

MSK conditions are the leading cause of disability adjusted life years [1] and in the UK, they account for approximately 14% of General Practitioner (GP) consultations [2]. Meeting the demand for musculoskeletal (MSK) healthcare is a significant challenge and part of proposed solutions is first contact physiotherapists (FCPs). These are autonomous practitioners who have been introduced to streamline MSK care pathways, provide faster access to specialist MSK healthcare, and release GPs' MSK capacity to manage other patients. FCPs are experienced MSK clinicians with advanced clinical practice skills able to assess, diagnose and manage the full spectrum of MSK patients, including complex cases [3].

First Contact Physiotherapy (FCP) is a primary care model that provides patients with direct access to physiotherapists, most commonly for the assessment and management of musculoskeletal disorders (MSK), without the need for a prior assessment or referral from a GP. The GP contract [3] pledges central government funding to primary care networks (groups of general practices working together) throughout the UK for the implementation of FCP services.

A small body of literature has shown value of the FCP model of care in the UK [4], [5], [6]. This is supported by several pragmatic service evaluations which all demonstrate similar positive findings albeit these were mostly small studies of individual services [4], [5], [6], [7], [8]. Positive findings included clinical effectiveness, patient and staff satisfaction and financial savings. Physiotherapists were shown to be able to appropriately manage most patients and the service appeared acceptable to patients and GPs [4], [5], [6]. Importantly, most patients were managed utilising a tailored self-management strategy within two appointments [4], [6].

Nevertheless, several more nuanced issues have been highlighted in qualitative studies of FCP services [9], [10] which suggest the need for a cultural shift from both a patient and professional perspective to enable the successful implementation of FCP. This included a shift from the patient's perspective where they see their GP as their first contact practitioner and a shift from the physiotherapists' perspective whereby the FCP role is seen as a reconceptualization of their traditional role, to one that mirrored the GP approach to working [9]. Since 2018, a rapid roll-out of FCP services across England was stimulated by the Elective Care Transformation Programme (ECTP) within the NHS England's supported pilot of FCP services [11]. Services involved in the ECTP FCP pilot were required to participate in the FCP National Evaluation. The third phase of the evaluation was a national mixed-methods evaluation of the FCP model of care. Here, the authors report the qualitative findings of this Phase 3 evaluation.

Overall aim

The overall aim of the phase 3 evaluation was to evaluate the FCP model of care against predefined service aims and success criteria.

Objectives of the qualitative evaluation

Achieve a-priori agreement of the FCP's service aims and success criteria, against which the new FCP model of care could be evaluated

Describe the experiences of FCPs, GPs and general practice staff.

Describe the role of the FCPs in providing advice about work in the context of the patient's presenting MSK condition.

Identify barriers to, and facilitators for, the successful implementation of the FCP model of care.

Provide recommendations for the scalability and successful implementation of the FCP model of care.

Methods

Agreement of service aims and success criteria

The Evaluation team drafted a list of five service aims and 12 success criteria based on published literature and the Elective Care High Impact Interventions Implementation Framework [4], [5], [6], [7], [8], [9], [10], [11]. The draft service aims and success criteria were made available to CSP's interactive (iCSP) FCP network, the FCP steering group and presented to a Patient and Public Involvement and Engagement (PPIE) Group for discussion and finalisation. This paper reports on six of the 12 success criteria, developed at the start of Phase 3, pertaining to the qualitative data collection (success criterion 2, 4, 7, 10, 11 and 12, shaded grey in ). The development of these success criteria and the quantitative component of the evaluation (Stynes et al. Quantitative companion paper, 2021) addresses the remaining six criteria.

Table 1

Aim A: FCP services should reduce the workload of GPs

Success criterion 1

The percentage of patients consulting the FCP who report (within 3 months) visiting their GP for the same problem will be: 25% or less (fully met), 26 to 50% (partially met), 51% or more (not met).

Aim B: FCP services should provide assessment and self-management advice.

Success criterion 3

Patients will report receiving self-management information/exercises from their FCP relating to their joint or muscle symptoms. 70% or more (fully met), 50 to 69% (partially met), 49% or less (not met).

Aim C: FCP services should provide high quality care and a good patient experience to patients with MSK problems

Success criterion 5

Patients should report improved MSK health at 3 months (as measured by achieving a minimal important change of 6 points on the MSK-HQ): 51% or more (fully met), 40 to 50% (partially met), 39% or less (not met).

Success criterion 6

Patients report being 'Likely' or 'Very likely' to recommend the FCP service to friends and family. 80% or more (fully met), 60 to 79% (partially met), 59% or less (not met).

Aim D: FCP services should support patients to remain in/return to work

Success criterion 8

Patients in employment report receiving specific advice about work. 75% or over (fully met), 50 to 74% (partially met), 49% or less (not met).

Success criterion 9

Patients will report less impact of their MSK condition on work performance at 3 months (as measured by the Stanford Presenteeism Scale): 51% or more report reduced impact (fully met), 40 to 50% (partially met), 39% or less (not met).

Aim E: FCP services should provide staff with a positive experience

Study design

For this qualitative investigation, data were collected via semi-structured interviews and focus groups. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [12] was used throughout to ensure necessary components of study design were reported. The published literature regarding FCP and the service aims and success criteria () helped to provide a framework to develop the topic guides for the interviews and focus groups.

Participant recruitment and data collection process

FCP services were invited to participate in the qualitative component via the interactive CSP (iCSP) network. A link FCP, usually the lead physiotherapist in the service, was identified for each participating site.

Participants were recruited in two stages (December 2018 and January to February 2020). Participant groups included patients who had attended the FCP service, FCPs, GPs, administration staff, and commissioners. A purposeful sampling method was used to recruit FCP services based on their delivery model to optimise information-rich cases [13]. Individual participants, from each participant group, were recruited by convenience. During the recruitment process the link FCP contacted all potential participants and provided them with an information sheet with all those agreeing to participate signing a consent form. A nominated code was given to each participant in order to preserve confidentiality and anonymity. Patient participants were interviewed individually to ensure each participant was allowed the opportunity to contribute fully. Thirteen of the 25 staff participants were interviewed in focus groups.

The interviews and focus groups were recorded using digital voice recorders, transcribed verbatim and coded by the evaluation team. The transcriptions were uploaded into QSR International's qualitative data analysis NVivo 11 Software.

Data analysis

This evaluation used a hybrid deductive and inductive thematic analysis [14], [15]. The service aims and success criteria and published literature regarding FCP provided a priori theories that informed the deductive analysis and concurrent inductive analysis allowed the emergence of novel themes. In accordance with COREQ guidelines [12] transparency in data coding is described. All transcripts were coded by two researchers (FM, RG) with co-investigators resolving any disagreements. A total of 50% of the transcripts were joint-coded. Previous research has shown this method is adequate to demonstrate consistency in coding, interpretations and inferences made by the lead researcher [16]. Using this method demonstrated excellent agreement in coding and analysis of the data and no further joint coding was deemed necessary.

Results

Sites and participants in the qualitative data collection

Sites

In stage 1 two sites were visited. In stage 2, four new sites were visited and one site from stage 1 was revisited. The second site from stage 1 no longer delivered an FCP service. Site visits to Scotland and Northern Ireland were cancelled due to the COVID-19 pandemic. Sites varied in the number of GP practices and population serviced and the service model delivered. This ranged from a single GP practice (site 2) with a population of 10,000 to 68 GP practices with a population of 800,000 (site 6). In one site, the FCP was employed directly by the general practice (site 3). In the remainder sites, there were a number of employment models ranging from primary care FCPs employed by a GP Federation (site 5) to a secondary care outreach model where FCPs based in secondary care were delivering sessions in primary care community settings and general practice (sites 2,4 and 6). In most sites, financial support was from commissioning organisations and was frequently FCP pilot initiative funding. As a consequence of this variability in funding, the FCP sessions per site varied. On average, most GP practices had an FCP located in their practice between 0.5 to one day per week. gives details of the FCP sites included.

Interview and focus group participants

Over the two stages there were a total of 39 participants, this included 14 patients, 8 GPs, FCP 10 and 6 general practice administration staff. The duration of each interview and focus group ranged between 25 and 75 minutes. In total approximately 20 hours of audio data were recorded. Participant details are provided in .

Table 3

Data collection point 1

Data collection point 2

Data collection point 3

Data collection point 4

Data collection point 5

Data collection point 6

Evidence pertaining to the six qualitative service aims and their respective success criteria are presented below.

Success criteria 2-GPs' discourse reflects confidence in the FCP service and competence of the FCPs.

GP participant discourse reflected confidence in the competence of FCPs, and GPs welcomed the addition of FCPs to the general practice workforce:

"It has been a fantastic addition actually. And I think I've seen patients who have seen [FCP] subsequently, and they've been delighted with the treatment that they've got. I think we're very lucky for [FCP]'s experience, I mean it's Advanced, so I don't know how you know, how realistic that is to replicate across the whole population. Because you know, there's always going to be variability in the experience and expertise. But so far it's been almost all positive"GP 8

The experienced FCP referenced by the GP above was representative of the FCP participants demonstrated advanced practice skills (), in line with the recommended guidelines for FCP roles [3]. The aim that FCP services should reduce the workload of GPs (service aim 1) had been an important narrative in the national FCP agenda on the basis of FCP services unburdening GPs by reducing their MSK patient workload. The stage 1 data collection had evidenced this as unclear and a complex construct. The stage 2 data collection reinforced these findings with the overriding consensus that there was currently insufficient capacity in FCP services to unburden GPs. For example, the site where 1 FCP provided 1 day of access for 20 GP practices:

"I don't think I've reduced the burden on GPs in terms of, I don't think I've increased their capacity, purely because I'm doing two sessions for 22 GP practices, so I don't think they'll notice a difference"FCP 4

When the potential to positively impact GP workload by addressing the mismatch between FCP capacity and MSK demand was explored it was viewed as a realisable objective. However, there were thought to be certain caveats. The first of these was the nature of patient complexity and comorbidity:

"Sometimes it's appropriate to you know, when I'm seeing you know, Mr Smith about his diabetes, and he wants to talk about his knee pain you know, his osteoarthritis, then fine you know, that will always carry on."GP 3

The second caveat related to patient beliefs and understanding, with some patients likely to default to their GP as a first point of contact: "Well again, I think the patients have this expectation that they come and see the GP at the GP surgery" (GP 3). However, this was acknowledged as potentially being generational: "I think elderly patients possibly more so" and somewhat related to a misunderstanding of physiotherapy and the FCP role: "when you mention physio, often they'll say oh, I don't want someone pushing and pulling me around. And it's saying actually, you're not going to be pushed and pulled around, you know, this is somebody who is going to assess you, diagnose"(GP 3).

It was acknowledged that the funding gap in existing service models needed to be addressed to release capacity and realise this objective. A practice manager (and CCG commissioner) and a GP both spoke of the 'bravery' required in this vision:

"I think as you said it's sort of bravery. I think if you look at pure appointment numbers, and if every MSK issue went to the physiotherapist, then you could probably justify dropping a GP clinician. But it's a... you've got to have the balls to do it"GP 4

Whilst the current model of FCP delivery had apparently failed to demonstrate a reduction in GP workload, the evaluation provided a novel insight into the impact of FCP on GP work experience that was seen by participants as equally important. Specifically, FCP was seen as introducing an MSK specialism into the practice. Not only was this seen as a welcome clinical resource for patients but it provided support and up-skilling to GPs and the wider general practice team. There were multiple examples of this, ranging from the informal conversations to more formal training sessions provided by FCPs:

"When we have a multidisciplinary...team meeting. Talking about complex patients, we can include those first contact practitioners. They may not be doing what they would do if they were face to face to a patient. But they can provide help and support to the whole team about understanding those areas. For instance, we're all learning about Start Back at the moment, they can train us in Start Back"

Success criteria 4-Patient discourse reflects self-efficacy and confidence in self-management techniques.

Success criteria 7-Patient discourse reflects a positive experience of FCP.

The service aims and success criteria 4 and 7 are reported together.

Patient discourse reflected patient expectations in consideration with the provision of advice around self-management techniques by FCPs and confidence therein. Particular reference was made to the focus on rehabilitation rather than pain relief and this was contrasted to GP care with FCP welcomed as an introduction of an MSK specialism within general practices:

"My first impression, it's been excellent, it's had me in and out of here way quicker than it would have done if I'd have had to wait for the GP. And actually [FCPs] knowledge and expertise is much more specific ...than possibly a GP who again, I'm just stereotyping, who possibly would have focussed on the pain, and the pain relief, rather than the rehabilitation and fixing the problem. Or potentially referring me to a physio, so it's cut that stage of it out"Patient 7

Patients spoke confidently about the self-management advice they had been given and also described an associated sense of self-efficacy:

"So it was years of, oh no, my back's gone again, and then regretting, oh why haven't I done my exercises? And that's why I do the exercises [FCP] has given me. Yeah, and there's a switch, a change in how you take control of your own healthcare really"

Satisfaction with FCP services was reported by all patient participants. Furthermore, analysis of patient satisfaction was reported as overwhelmingly positive.

"the positiveness that we've had back has been quite overwhelming. 100% satisfaction, positive, excellent reviews from patient groups and patient participation"

As seen above, inherent in the patient satisfaction expressed with FCP services was the speed and ease of access. However, this access required facilitation by GP reception/administration staff or via other routes (such as GP triage) as most patients were unaware of the FCP services within their general practice. In some cases, where patients were signposted to FCP following a GP consultation, it undermined the first contact principle. Patients also appeared to be cognisant of the changing face of primary care and general practice, the increasing role of administrator signposting in this evolution and how FCP sat within this contextual reconfiguration.

"I think it's great to involve other... what do you call yourselves... practitioners, other care givers, other people who know what they're talking about. So that the GP can see the people who are really sick and need to see the GP"Patient 7

Success criteria 10- Physiotherapists' discourse reflects confidence in their competence to offer advice in consideration with work-related issues.

Success criteria 11-Patients' discourse reflects perceived benefit from the advice offered by the FCP in consideration with work- related issues.

Success criteria 10 and 11 are reported together as they are closely linked. An area of particular interest for this project was that of work, and the role that FCPs play in providing employment support and advice.

All of the FCPs stated that they would consider work-related issues with every patient of working age. Of the patient participants, the majority reported discussing work and receiving advice from the FCP. The age of some patient participants meant that they were retired, however the patients who had received employment related advice found this helpful.

"So I had taken sick leave the first week when I was back, and then... So the next week she said, yes I could go but only two days a week...I must wear the sling except when I'm at my desk. So I could take it off when I'm sitting at my desk, but at all other times I have to wear the sling, so that's really helpful. And then last week it was certain exercises I had to do when I'm at my desk...and that's really helpful"

Two FCPs spoke specifically about using the Allied Health Professions Health and Work Report and finding this useful. However, training to use the report was patchy and inconsistent and the practical application of the form itself was described as cumbersome.

Participants from each group saw the value in FCPs being able to sign patients off work with legislative authority. Such was the strength of feeling regarding this sentiment that the current situation (no legislative authority for FCPs) was seen as strange and counterintuitive. Indeed, GPs saw FCPs as better equipped to make this assessment and described themselves as often following FCP advice. As this one GP described:

"I completely agree, I think it's crazy ... because what we do is just go on whatever the physios have deemed to be appropriate. So they say, you need a couple of weeks off we'll just do a sick note for a couple of weeks you know. We don't then do a whole reassessment, so actually; literally it's just signing a form. Which it seems crazy"GP2

The only concern expressed in consideration with this came from an FCP who paralleled signing patients off work with the risks associated with other advanced practice skills:

"in terms of prescribing, I'm scared of the, maybe the addictive nature of it, you don't know really what they're on, or what they're taking, and you're being held accountable for that. But then in terms of work, if you sign someone off who, you then could get them into this cascade of being off work. So I don't know which one scares me more"FCP 4

Nevertheless, the overwhelming consensus was that employment advice was integral to the FCP role and greater legislative accountability should be given to FCPs.

Success criteria 12-Staff discourse reflects a positive experience of working with and in the FCP services.

All the FCPs found their role a rewarding and enhancing career opportunity. For this physiotherapist it was extremely positive being at the front end of the patient journey.

"As a clinician it's fantastic to be at the front of a pathway, to be seeing people when it's first happening, when they're all, even, I mean I used to work in chronic pain as well and there you're seeing people at the very end of the pathway"FCP 5

The first contact nature of FCP work was reported as both rewarding for the physiotherapist and beneficial for patient care:

"Yeah, I love doing it. I really love working in the clinics. I feel you're just getting to people so much quicker and giving them the right information to make changes"FCP 9

Nevertheless, the complex, unpredictable nature of this work was acknowledged as introducing some challenges and associated risk: "You don't know what's coming through the door. You can't look at your list two weeks in advance and say, oh I've got X, Y and Z coming in then, let's read up on it, it's on the day you know, you have no prior warning" (FCP 7). Consequently, the FCPs spoke about the need to manage risk and associated competency requirements.

In both stages of data collection FCPs discussed the novelty of working in a way that emulated the GP model of care. As one FCP reported:

"I can say try these for a month and if it doesn't work, they know that I'm in primary care... they can come back at any time. They could book an appointment with me tomorrow if they wanted to. So that reassurance for them is also quite helpful"FCP 1

Beyond GP and physiotherapy participants the benefits of FCP were widely reported by administrators and practice managers:

"I would highly recommend the service. We'd struggle without it if you took it away"

FCPs were seen as highly specialised MSK practitioners. These benefits were felt to be greater when the FCP service was collocated.

Discussion

This qualitative evaluation demonstrated success in all of the service aims and success criteria (). FCP was well received by staff and patients alike. These findings corroborate previous evidence describing the safety, acceptability and efficacy of FCP [4], [5], [6], [7], [8], [9], [10]. Furthermore, confidence in the competence of FCPs was described by GPs and patients. The FCP participants were experienced clinicians with advanced practice skills. It cannot be assumed that the findings of this evaluation apply to FCPs with less experience. In a previous evaluation, GPs were concerned that more work would be 'bounced back' to them with less experienced physiotherapists in FCP roles (9).

FCPs saw supporting patients to remain in/return to work as integral to their role. Patient discourse reflected perceived benefit from the advice offered by the FCP in consideration with work related issues. All participants groups advocated a greater role for FCPs in providing work advice including signing patients off, and back to, work. This echoes previous work [17] where the majority of GPs and physiotherapists who were questioned indicated that there could be benefits for patients if physiotherapists were involved in monitoring and issuing sickness certificates. A recent qualitative study exploring patient expectations of FCP [18] found that patients were seeking advice about whether, and when, they could do things, including work.

Physiotherapists described working as an FCP as a positive experience as it provided them with a rewarding career opportunity and the role gave patients timely access to their specialist care. However, some also expressed concern with the unpredictable nature of this work acknowledged as introducing some challenges and associated risk including staff burnout. This concern has also been reported elsewhere [19] with anxieties around FCPs' wellbeing expressed both in terms of workload, diagnostic uncertainty and the subsequent risk associated with the FCP role.

Despite the widespread patient satisfaction described, there was a lack of awareness among patients about FCP services. Consequently, patient access to FCP services was on the whole reliant on signposting from reception/ administration staff. This has been previously described and could present a challenge to receptionists in terms of explaining new consultation methods to patients [9], [20], [21] and this potential unintended consequence of FCP, needs considering within the wider agenda.

Reduction of GP workload, as a result of the implementation of FCP, was not evident in the discourse of participants. The impression was that this was a result of the complex interaction of a lack of patient awareness of FCP services, limited FCP capacity and the propensity for some patients to default to their GP as the first point of contact. This complexity on the basis of the impact of FCP on GP workload has been reported elsewhere [9]. This is important because if services are built and promoted on the premise that they will reduce GP workload they will arguably fail to meet that target. It was also acknowledged by participants that the current funding models were seen as insufficient to realise the capacity increase required to genuinely impact GP workload to a measurable level. This is a pertinent finding with the current nationwide commitment to FCP whereby a population of 50,000 receives funding for 1 full time equivalent FCP [7].

The FCP service was also acknowledged as introducing an MSK specialism and a resource for GPs and the wider general practice staff. Although the introduction of FCP as an MSK specialism has been reported before [9] the potential for FCPs to support and even up skill GPs, has not. This mirrors previous evidence whereby physiotherapists provided effective undergraduate medical education for musculoskeletal system training [22]. This appears to be an important potential of the FCP role.

Strength of this evaluation is that it is the first nationwide evaluation of the FCP model of care. It is further strengthened by the multi-method approach, representation from all stakeholder groups and the wide variety of service models included. A limitation of the evaluation is that the authors were unable to collect data from some additional FCP sites in devolved nations due to travel restrictions during the Covid-19 pandemic and this somewhat limits transferability of the findings.

In conclusion our evaluation shows that the FCP model is well received and supported by all stakeholder groups. It is evident that work is evolving continuously within professional Physiotherapy networks with resources available providing guidance and advice in consideration with establishing successful FCP services. On-going evaluation and implementation research is needed to explore the most effective strategies to implement FCP services into primary care within the UK or in other countries that could promote this model of care. Future research should explore staff experiences and outcomes including satisfaction and impact on workloads for GPs, FCPs and administrators. Additionally, the cost effectiveness of the FCP models could be explored, when compared to MSK patients accessing GPs as their first point of contact.

Ethical approval: None required.

Funding: The evaluation was funded by the Chartered Society of Physiotherapy CSP Charitable Trust, Registered Charity No 279882 and The Work and Health Unit, a cross-government unit, jointly sponsored by the Department for Work and Pensions and the Department of Health and Social Care.

Conflict of interest: None declared.

Acknowledgements

We would like to thank all the participants who took part in the interviews and focus groups.

We thank the CSP FCP Coordinating team for their help in recruiting FCP sites for this Evaluation.

References

3. NHSE, British Medical Association . 2019. Investment and evolution: a five-year framework for GP contract reform to implement The NHS long term plan. [ Google Scholar]

10. Goodwin R., Moffatt F., Hendrick P., Timmons S., Chadborn N., Logan P. First point of contact physiotherapy; a qualitative study. Physiotherapy. 2020 [[ PMC free article] [ PubMed] Google Scholar]

11. NHS England and NHS Improvement . 2019. Elective Care High Impact Interventions First Contact Practitioner for MSK Services. May. [ Google Scholar]

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Evaluation of the First Contact Physiotherapy (FCP) model of primary care: a qualitative insight

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First Contact Physiotherapy (FCP) is a primary care model where expert musculoskeletal (MSK) physiotherapists undertake the first patient consultation, to enhance MSK-patient care and free-up GP capacity. The authors report the qualitative findings from the FCP National Evaluation (Phase 3) which evaluated the FCP model against pre-agreed success criteria.

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https://www.csp.org.uk/professional-clinical/improvement-innovation/first-contact-physiotherapy-0

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https://rcpod.org.uk/news/press-release-health-education-england-publish-first-contact-practitioners-and-advanced-practitioners-in-primary-care-podiatry-a-roadmap-to-practice

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Information for First Contact Practitioners & Advanced Practitioners about First Contact Dietitians - a diagnostic clinician working in Primary Care. On this page you will find guides, example job descriptions and the HEE roadmap to practice.

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Musculoskeletal First contact practice is an increasingly established model of care designed to deliver a streamlined, patient-centred service and support the growing demands on general practice. Our goals: Support GPs by taking on the MSK caseload creating capacity to focus on medically complex pat…

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Dietitians in primary care a guide for general practice

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FCP Dietitian -A guide for general practice 

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FCP Dietitian -A guide for general practice 

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A day in the life of a First Contact Dietitian. BDA. 

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A day in the life of a First Contact Dietitian. BDA. 

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Are you considering a career in Primary Care as a First Contact Dietitian? The BDA is here to support you to move into this exciting, emerging area of practice. In this article, we hear what a day might look like as a First Contact Dietitian*
08.15am - I log in to the clinical system to see who is booked into my clinic. My clinics are set up to run face to face, all are 30-minute appointments with 50% booked on the day and 50% booked in advance.

08.28am - My screen changes to alert me that my first patient has arrived, having been booked in from reception triage just this morning. I press the key to call them into the clinic room and have the four minutes I know it takes them to walk down the corridor to read their notes to get an idea of why they are booked in to see me.

08.32am - Jessica is 24 years old and has abdominal cramps and bloating. I take a full history of her symptoms and explore Jessica's Ideas, Concerns and Expectations ¹. Jessica worries about the bloating as on days when it is bad, she has had people ask if she is pregnant. Jessica and I agree that we will conduct some initial blood tests and when we have these results, we can agree next steps. I order the agreed blood tests on the clinical system and book a follow up appointment for 10 days' time. Jessica thanks me for my time and lets me know that she feels reassured.

09.09am - My next patient has also been booked in to see me on the same day after phoning reception and requesting an assessment with the first contact dietitian. Jason is 32 and has been off work for the last 6 weeks due to lower back pain. I can see from his notes that he has recently been seen by the First Contact Physiotherapist, who has advised Jason to get support to manage his weight as his lower back pain is likely exacerbated by having a high body mass index (BMI). Jason feels that it's a good time for him to address his weight and therefore has requested this appointment. I take his blood pressure, review and discuss his recent HbA1c and lipids, we discuss his family history of heart disease, smoking etc to allow me to calculate his QRISK score and to see what referral options are available. Using a patient-centred approach, Jason and I agree that he would benefit from being referred into the local weight management groups offered by the community dietetic team. We discuss goals and I task the admin team with actioning the referral for the groups. Jason and I agree that he will make further appointments with me in future depending on his progress with the groups.

09.30am - The next patient is in the waiting room, also booked in on the day and it's a child. I can see from their notes that they have already seen the GP this morning who has assessed for any worrying signs and symptoms and the GP wishes for me to speak with the family about selective eating. This, I know I can do. Coming from an adult background, I always worry about seeing children but as per my agreed scope of practice, I only see infants and children who have been referred following an assessment by a GP. This consultation goes very well and mum and child leave with mum reporting she feels reassured and confident with the plan we have put in place. I have not booked a follow up appointment, but importantly, I have provided safety netting advice so that the mum knows what to look for and when to call the practice for further support.

09.52am - I've now managed to get ahead of schedule as my next person is due at 10am and hasn't arrived yet so it's a quick trip out of my room to get a drink. The rest of my morning appointments are pre-booked so I can relax a bit. On the way, one of my GP colleagues, Nisha, stops me to ask a question about a patient she has seen that morning who has a stoma. Nisha wants to know whether they still need the magnesium that's on their acute prescription. We discuss the case and I agree to have a look at the notes and let her know.

10.05am - I call my next patient and can see that this is an Orlistat review. As a non-medical supplementary prescriber, I see all the Orlistat reviews within the practice as it's a caseload that the dietitians can manage well that frees up significant amounts of GP appointments. I call the person in, take their weight and discuss their progress - they've lost another 3kgs since last month, amazing! Although I'm a non-medical prescriber, I haven't yet been able to get my name added to issue prescriptions so I send a quick task to the GP to request they authorise the next month's prescription. As I have been seeing this person for a while, I already have a clinical management plan in place and at each appointment, I will check to ensure that no new medications have been started and provide drug counselling.

10.28am - I have a welcome structured 30-minute admin break in the middle of my morning. This is a very important part of my day as it's an opportunity to leave my clinic room, make a cup of tea and most importantly - mix with the other members of the Primary Care team who are doing the same. The practice gives everyone a 30-minute mid-morning and mid-afternoon break for this exact reason - otherwise you could go all day in your room without interacting with any of your work colleagues. For me, it's an opportunity to have a quick debrief with one of the GPs (who happens to be my supervisor) following my morning patients. I summarise my consultation with Jessica, my supervisor asks a few probing questions to explore my thoughts on what I will be looking for at the review and we agree that this will be a great case-based discussion to bring along to my next formal supervision session in 3 weeks' time.

10.57am - Back in my room and the next consultation is a phone review for Brenda - a housebound patient who has not long been discharged from hospital. She has declined input from the local community dietetic service as she doesn't want lots of people visiting her at home. I find that it is common in Primary Care to identify patients who need health care professions input, but will only engage with their GP practice. The community nurses have been checking her weight and she is slowly gaining weight, but her BMI is still only 15kg/m2 and she has an improving category 2 pressure ulcer. Whilst it's challenging to get all the information I need over the phone, I respect Brenda's wishes and know that if I didn't contact her in this way, she would not get the dietetic support she so obviously needs. Brenda has been on 2 nutritional supplements per day for the last 4 weeks, we discuss food fortification options now she is at home and agree a review for 6 weeks' time. I try to limit the number of follow up appointments I book for people but I know Brenda needs this.

On this occasion, no change to the nutritional supplements was required, however if a change was required, as per agreement with the practice, I'd make the amendments to the prescription on the system and send to the GP for it to be issued. I can do this, regardless of my status as a non-medical prescriber because supplements are not prescription only medicines. I would of course, as with any dietetic intervention, ensure there are no contraindications for the supplements (such as allergy/drug interactions) and provide appropriate counselling where this is needed. Examples include ensuring the correct IDDSI level and checking cultural and personal requirements (such as Halal/vegan/vegetarian).

11.33am - The last person of the morning is Dave and he is in the waiting area. I saw Dave last week and based on his history and symptoms, we ordered blood tests that included a coeliac screen. I quickly check the IgA tissue transglutaminase (tTG) result before calling him in and it's 55 U/ml. When he arrives, I can see that he is nervous. Dave has a strong family history of coeliac disease and has seen how other family members have managed this. We discuss the results and I explain, in detail, that it's not conclusive but highly suggestive of coeliac disease and that a biopsy will be needed to provide a definitive answer. Dave has lots of questions about this, some I can answer, but for some of them (for example the wait time) I advise Dave that I don't know but will find out and let him know. I ensure Dave knows that he must keep eating gluten up until his biopsy and that I will get back to him when I have answers to his other questions.

12.04pm - I am relieved that it's the last appointment of the day for me as I have never referred anyone for oesophago-gastro-duodenoscopy (OGD) and duodenal biopsies before so I need to find someone who can help me. I go to see who is in the staff room and Rich the Advanced Practice paramedic is there. Unfortunately, he has also never done this before, so I go and knock on the door of the duty doctor, Jenny. Jenny is always super helpful, but I can tell she is under pressure today. I explain that I need her help with Dave, we discuss what needs to happen - she acknowledges it needs sorting out soon but it's not urgent so we schedule a time when we can go through this together at the end of the week. In the meantime, she gives me some advice on how to find the answer to Dave's questions. Only a very quick 5-minute chat with Jenny but super important and helpful in ensuring I'm not going to spend lots of time worrying that I had missed something with Dave.

1.00pm - After a quick walk and sandwich for lunch it's service development time for me this afternoon. In line with the recommendations made by Health Education England, my time is spent with an 80% split of clinical time alongside 20% of time for development ². The PCN have highlighted some priority areas that they want the dietitian to support and I've been tasked with developing a plan for this. As part of the enhanced health in care homes ³, people living in care homes should expect the same level of support as if they were living in their own home. The PCN therefore are aspiring for better collaboration between community and Primary Care providers. For me this means working with the community dietetic team, who are commissioned to deliver diabetes structured education, to agree how we can better provide this education so that it meets the needs of all residents whether in their own home or a care home. I did not know the community dietetic service before this role so found their contact details via the internet and arranged a virtual meeting to get to know the team and how best to work together to ensure system wide benefits.

3.30pm - I'll be in a different practice tomorrow and won't be here for another week so I always try to finish my day by ensuring there are no outstanding tasks. I've researched and found the answers out for Dave's questions and use Accurx to text him. I am meeting with Jenny on Friday afternoon in my other protected development session, so that we can refer him to the local secondary care trust for his OGD and biopsies.

I've gone through my emails and tasks from the multi-professional general practice team. Just as I'm about to log off, I remember that I agreed to check the stoma patient for Nisha. I look through the notes and I can't see any letters to suggest that he is known to the hospital team so I call the community dietetic service. They advise that he did not attend his last appointment and so was discharged from the service as per local policy. I reflect on what an eye-opening experience it has been for me working in Primary Care where we cannot simply discharge patients. I decide the safest thing to do is probably for me to fully assess the patient notes so that I can advise the GP appropriately. Fortunately, I see that I have a free slot in my clinic in the morning so I make a note to myself to use that time to do this. I send a quick message to Nisha to let her know my plan so she knows I haven't forgotten and its home time.

Working in Primary Care as a first contact dietitian pushes me to my limits clinically every day. It's hard work but hugely rewarding being at the start of a person's journey, ensuring they are seen by the right clinician and given the right advice and treatment at the first point of contact into the health service. Primary Care also allows me to address some of the health inequalities that are created by the system where strict referral criteria or access policies may mean that those patients who would most benefit from dietetic intervention often do not receive it.

Fortunately, I feel I have a supportive network of colleagues but this has taken me a lot of time and initiative to establish. For example, before I accepted the job offer, I checked that the PCN offered a CPD programme that included both a clinical and a roadmap supervisor to enhance my Primary Care specific skills. This ensures I can meet the standards expected of me as an HCPC registrant as well as the PCN meeting CQC requirements ³. I did not have links with the local nutrition and dietetic department before starting this role and so I have prioritised developing a partnership with them which is mutually beneficial. This also ensures I can access dietetic supervision, which cannot be provided by the PCN with me being the only dietitian within the team.

The BDA has developed a lot of resources to support FCD, including an education and training page, and a Basecamp group to provide peer support. Email info@bda.uk.com if you'd like to be added to the Basecamp.

*This is based on real life examples of dietitians working in Primary Care in FCD roles as well as events discussed within the BDA Primary Care roundtable discussions. Thank you to those that took part in these events and shared their experiences with us to help the future Primary Care workforce.

References

1. What are consultation models for? - Claire Denness, 2013 (sagepub.com)

2. Roadmap FAQs | Health Education England (hee.nhs.uk) (see supervision Q4)

3. NHS England " Enhanced health in care homes

4. CQC mythbuster

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A day in the life of a First Contact Dietitian

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Are you considering a career in Primary Care as a First Contact Dietitian? The BDA is here to support you to move into this exciting, emerging area of practice. In this article, we hear what a day might look like as a First Contact Dietitian* 08.15am - I log in to the clinical system to see who is booked into my clinic.

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Management of the high-risk foot

Podiatrists are experts at early diagnosis and management of the diabetic and neuropathic foot.

From 2015 to 2018 there were 27,465 lower limb amputations related to diabetes in England, an 18.3% increase of amputation linked to diabetic ulcers from the previous period. Podiatrists are highly skilled in the early detection and management of foot ulcers, playing a crucial role in the prevention of avoidable amputations.

Diagnosis of new problems

Podiatrists are experts in the diagnosis of conditions affecting the foot and ankle. Within primary care, the FCP podiatrist will apply their specialist knowledge of foot health across a broad range of clinical presentations spanning musculoskeletal, cardiovascular, neurological, dermatological, or age-related conditions. FCP podiatrists are trained to request and interpret a range of diagnostic tests, such as x-ray or blood tests, to help inform a diagnosis. Upon diagnosis, FCP podiatrists can provide personalised self-management advice, formulate treatment plans, or refer to other services.
Our goals

Early identification of problems to prevent chronic foot health issues and on referral to secondary care

Management close to home

Reduction in avoidable amputations

"8% of GP consultations for MSK are for foot and ankle pain. Enabling people who have foot pain to self-refer to a podiatrist working as a FCP ... has the potential to significantly reduce the burden of foot and/or ankle pain on GPs, improve patient's quality of life and prevent work-related absence."

Support of people living with long-term conditions

FCP podiatrists have expertise in the support of people living with a range of long-term conditions. Some FCP podiatrists have additional expertise in focussed areas of clinical practice, such as diabetes, peripheral vascular disease, or musculoskeletal and rheumatic disease. FCP podiatrists are trained to request, interpret, and apply a range of disease monitoring tests, such as x-ray or blood tests, to help inform changes to treatment plans. FCP podiatrists can access and supply medications. With additional training, FCP podiatrists can also adjust or prescribe a wider range of medications including antibiotics.
Our goals

prevent or delay the onset of long-term conditions affecting the foot or ankle

preserve foot and ankle health, reducing the risk of wounds, infection, or amputation

preserve foot and ankle function, reducing the risk of immobility, or secondary consequences of reduced physical activity

reduce foot and ankle pain and support people living with long-term pain

reduce hospital admissions and secondary care referral

lead medicine management for conditions primarily affecting the foot and ankle, saving GP time and resource.

20% of people aged 60+ in the UK are affected by Peripheral Arterial Disease, this is about 9% of the total population. Podiatrists specialise in the early detection and management of this condition preventing avoidable heart attacks, strokes, amputation and early death.

Maintaining physical activity and wellbeing

Poor foot health is a major barrier to mobility and social integration. FCP podiatrists support people to remain mobile, reducing the demand for home visiting services. Maintaining mobility also enables people to continue to access vital social activities such as work, family or carer responsibilities, or engagement in other religious or social networks integral to wellbeing.
Our goals

maintain and maximise mobility

keep people physically active and able to work

prevent or reduce the onset of long-term conditions through maintained mobility and physical activity

reduce falls and falling risk

enable independence leading to improved quality of life and reduced social exclusion

support personalised approaches to care, including self-management, and reduce referral to community or secondary care services

Podiatrists have a significant role in the public health and prevention agenda specifically around falls prevention, cardio-vascular risk reduction, medicines management and reconciliation, antibiotic stewardship and keeping people mobile and active.

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Management of the high-risk foot Podiatrists are experts at early diagnosis and management of the diabetic and neuropathic foot. From 2015 to 2018 there were 27,465 lower limb amputations related to diabetes in England, an 18.3% increase of amputation linked to diabetic ulcers from the previous period.

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There are two ways paramedics work in primary care;

1. Through a working relationship with a PCN and an ambulance trust; a rotational model where the trust remains the employer and supplies experienced paramedics to work with general practice to manage local population need. They can be involved in caseloads such as acute and unscheduled care in care homes, home visits or seeing and managing acute presentations in the practice.

2. Some PCN's recruit directly and prefer the opportunity to further train their own staff in other areas or to be the practice lead on frailty, admission avoidance or advanced care planning.

There are three main areas paramedics can support in primary care:

Urgent and unscheduled care

Paramedics are experienced in dealing with the unexpected and will conduct a detailed assessment and initiate a management plan knowing where the best place for that patient will be.
Our goals

manage urgent and unscheduled care to allow GPs to work with medical complexity

reduce conveyance rate to hospital

An evaluation of the first phase of the rotation paramedic pilot reported non-conveyance rates of at least 70%

"Paramedics bring a valuable skillset to primary care, in particular their grounding in the medical model, diagnosis and independent decision making and their experience in emergency and urgent care." Paramedic in primary care

Acute conditions

Paramedics can deal with acute or acute-on-chronic conditions freeing up the GPs to deal with more complex patients.
Our goals

manage triage for urgent conditions

responsibility for home visits for acute presentations

"Having niche skills from Paramedics adds to the depth of the offering that can be provided in General Practice, but being competent generalists for common conditions is the most important attribute." GP

Prevention of unplanned admissions

Paramedics can be the eyes and ears of the GP, conducting regular ward rounds at nursing and care homes or visiting vulnerable patients at risk of admission to support management at home. Paramedics are specialist generalists, and will add value and a unique perspective to the general practice and multidisciplinary teams.

Our goals

Studies have highlighted that the addition of paramedics in a primary care setting decreases GP workload.

A number of studies also document high satisfaction levels from patients who were visited by a paramedic in their home.

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There are three main areas paramedics can support in primary care: Urgent and unscheduled care Paramedics are experienced in dealing with the unexpected and will conduct a detailed assessment and initiate a management plan knowing where the best place for that patient will be.

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Webinar: Dietetic Roles in Primary Care 

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Webinar: Dietetic Roles in Primary Care 

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https://youtu.be/2dtj_5Sp1mk?list=TLGGrQSxPTqs_2kwNzEyMjAyMg

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Frail older adults Rehabilitation for older adults to stay well at home. Use of risk stratification tools, rapid access, assessment of the home and short-term interventions including advice on how people can be safely managed.

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Webinar: Dietetics AP and FCP roles in Primary care 

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Webinar: Dietetics AP and FCP roles in Primary care 

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https://youtu.be/wEho7PrjTps?list=TLGG3MY3mkC9PRIwNzEyMjAyMg

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First Contact Practitioners and Advanced Practitioners in Primary Care Occupational Therapy 1 1 

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https://youtu.be/2jzPwvVKrXs

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Webinar: Employing Occupational Therapists in Primary Care 

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Webinar: Employing Occupational Therapists in Primary Care 

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https://youtu.be/6ZWaTmjQthI