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Service designNov 27, 2020

First contact physiotherapy for MSK problems: lessons learned from Somerset

Ambitious plans to give patients with musculoskeletal (MSK) problems direct access to physiotherapists at a primary care level will only succeed if local services are designed in a coherent way.

That is one of the messages in an ‘early view’ report by Simon Ingram – an advanced physiotherapy practitioner and clinical lead for the first contact physiotherapy (FCP) service – and three colleagues who draw on their professional experiences at Somerset NHS Trust.

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With up to one third of GP visits involving MSK problems, physios are playing key roles

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Their report, titled Implementation of a provider based musculoskeletal first contact physiotherapy service model: Key points to consider, was published by the journal Musculoskeletal Care on 23 November.

It states that NHS England (NHSE) in their area has called for half the population to be given access to FCPs by March next year, with this being extended to 100 per cent by March 2023.

‘An integral part of the long-term plan for the NHS is to reshape primary care by introducing primary care networks (PCNs) and new roles,’ the paper states.

‘These roles aim to increase capacity, enhance the skill mix and reduce the pressure on general practitioners by ensuring patients see the right person, at the right time.’

Addressing MSK demand

Up to almost one third of GP appointments (estimates vary from 17-30 per cent) are for MSK problems, according to evidence cited in the report. ‘The FCP role aims to address the increasing MSK demand in primary care as well as having fewer touchpoints and ensuring the right pathway for patients from the start.'

An evaluation of more than 8,000 FCP consultations over two years found that most patients (87 per cent) were managed within primary care – showing the potential system-wide benefits of FCP implementation

However, the authors warn that, despite an ‘additional roles reimbursement scheme’ (ARRS), providing 100 per cent funding for band 7 or 8a clinicians, a number of challenges still have to be overcome.

A series of learning points from the Somerset model is summarised below:

Build relationships with key stakeholders

Engage local stakeholders early on. One way is to establish ‘task and finish’ working groups, involving MSK service leads, commissioners and primary care representatives.

Create links with primary care leads at local sustainability and transformation partnerships, primary care training hubs and higher education institutes, they suggest.

Patients and local communities ‘should be at the heart’ of any decision-making processes. ‘It is essential that co-production is embedded from the outset,’ the authors note.

Integrate into existing MSK services

The FCP should be fully integrated into existing MSK services, as employing them in an independent capacity ‘risks fragmentation’, they warn.

‘Working in primary care can be challenging due to the clinical complexity and the uncertainty this brings. Being part of an established MSK workforce can provide a support network and having mentors for those new into advanced practice is crucial to help maintain resilience.

‘Having an integrated workforce also provides more opportunities for ongoing training and continued professional development.’

An important aspect of the FCP role is to help to ‘upskill’ other members of the primary care team in MSK conditions, in part to help reduce pressures on the FCP.

Focus on ‘population health’

In Somerset, we have placed increasing importance on staff developing the 'softer' skills such as agenda setting, shared decision making and self-management support through health coaching [Simon Ingram and colleagues]

‘Improving physical activity is recognised to have both physical and mental health benefits. The FCP role is ideally placed in primary care to encourage health behaviour change through applying personalised care principles such as Making Every Contact Count.

There is a risk that some clinicians will focus too heavily on biomedical factors in terms of requesting investigations, non-medical prescribing and injection therapy. MSK conditions have been ‘over investigated’ and the benefits of many surgical procedures and injections are questionable, the authors suggest.

‘While these are important skills they are not essential and the emphasis … should be on first line management focusing on normalising age-related findings, lifestyle factors and identifying what matters most to the patients.’

‘In Somerset, we have placed increasing importance on staff developing the “softer” skills such as agenda setting, shared decision making and self-management support through health coaching.'

These skills should underpin the FCP delivery model and separate it from traditional community MSK triage or secondary care services, where the expectation of investigation and intervention is often greater.

Workforce planning

Workforce planning and developing staff ‘in-house’ depends on a long-term commitment at an operational level – perhaps using a ‘targeted release of clinicians’ to ‘fast track’ their development to advanced practice positions.

Establishing a longer-term vision for potential expansion of the role is vital as primary care networks may wish to recruit additional clinicians in line with the proposed increased ARRS funding, the authors note.

Somerset has a population of 580,00, currently served by 13 primary care networks and 32 FCPs.

Governance framework

'One of the most attractive aspects of the provider model to the PCNs [primary care networks] is that the local MSK provider takes responsibility and accountability for governance issues, such as contracts of employment, ongoing training and ensuring an appropriate level of competency, as stipulated in the [NHSE] direct enhanced service specification.'

Monitoring and evaluating the performance of any service is imperative and establishing the key performance indicators should involve input from stakeholders across the system, Mr Ingram and his co-authors – Rob Stenner, Trish Acton and Katherine Armitage – conclude.

Implementation of a provider based musculoskeletal first contact physiotherapy service model: Key points to consider Visit: https://doi.org/10.1002/msc.1527




Author: Ian A McMillan
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