A first contact physiotherapy (FCP) hub model is giving patients in a densely populated area access to services through their GP while also ensuring integration, explains Susan Buckley from Derbyshire Community Health Services.
General manager Susan Buckley and the team at Derbyshire Community Health Services NHS Foundation Trust (DCHS) have been involved in implementation of FCP roles since being part of the national FCP pilot in 2018.
Working with the CSP, NHS England and NHS Improvement (NHSEI) and Health Education England (HEE), the team has ensured that the local FCP service provision remains consistent with national direction and guidance. DCHS has also shared lessons learned with regional and national groups, which has helped to shape FCP development.
Approach
The pilot site for FCP implementation in Derbyshire centred around Erewash Primary Care Network (PCN) with a large population of over 100,000 and 13 GP practices within a small geographical area.
Following discussions with the PCN, a hub model approach was agreed as the best option based on its size and geography.
Delivering the service from centralised hubs allows all 13 GP practices to refer their patients to an FCP service that offers consultations five days per week, and enables the service to maximise efficiency and maintain business continuity.
The two hubs in the PCN are located within community hospitals where the FCPs work alongside the outpatient physiotherapy and musculoskeletal (MSK) triage teams. The integrated service offer ensures that the added value of the FCP role is maximised by avoiding duplication and delivering efficient MSK pathways.
Eight FCP clinicians share the two full-time roles in the hubs, spending the rest of their time working in different parts of the MSK pathway, including triage and outpatient physiotherapy services. This appeals to the clinicians as a way or retaining their skills and improving job satisfaction. As the PCN has a small group of named FCPs, they develop strong working relationships and integrate with the practice team through regular communication, mutual shadowing opportunities, attendance at practice meetings and training sessions.
The FCP hub has continued to deliver a service throughout Covid 19, switching to a ‘virtual first’ approach in response to the pandemic, whereby the FCPs complete the initial assessment by telephone (or video call) and then provide face-to-face follow-ups where indicated. The virtual first offer is under regular review with the PCN as the situation continues to evolve.
DCHS is now working with a growing number of PCNs within the Derbyshire system. It has been important to work with each PCN to tailor the approach according to geography and population, which vary quite significantly across the county.
Set-up and implementation
DCHS was already working with Erewash PCN prior to the FCP pilot to provide an ‘on-day’ physiotherapy service pilot (reviewed by the King’s Fund). The decision for Erewash PCN to be the pilot site was influenced by the fact that there was an opportunity to build on the existing arrangements and relationships, working with the NHSEI guidance to implement the FCP service.
Implementing the FCP pilot model in 2018 involved working closely with the clinical director of the PCN, the practice managers and the Clinical Commissioning Group to establish a model that met the needs of the GP practices and the local population. The FCP service is funded via the Additional Roles Reimbursement Scheme.
DCHS is an established provider of physiotherapy and MSK triage services across the Derbyshire system. By virtue of its large workforce, with growing numbers of staff who have advanced clinical practice-level skills, the organisation was well positioned to take responsibility for ensuring that all clinicians received the appropriate training, mentorship and support in their roles.
There is a strong peer support structure with regular meetings to share learning, best practice and innovation. All the FCPs are physiotherapists working at band 7 and band 8 level, with many years of experience in MSK physiotherapy services.
Prior to publication of the FCP roadmap, DCHS ensured that all clinicians had completed competencies for various elements of the FCP role before working in the clinic. These competency documents were shared with HEE to inform development of the national roadmap.
Following publication of the roadmap, DCHS is supporting its FCPs with additional supervision and training to enable them to become accredited on the national FCP register. Many of the competency standards needed for FCP are also integral to the clinicians’ roles in MSK triage, MSK and direct access physiotherapy services.
Communication was essential throughout the implementation, as well as remaining flexible and open-minded in order to adapt the service offer and ensure it continued to meet the needs of all parties. The hub model was developed to balance the benefits of PCNs having daily access to a resilient FCP service that offers a seamless patient journey along the MSK pathway while remaining integrated as part of the practice team.
Benefits
For staff
- FCPs, MSK clinicians and outpatient physiotherapists work together in the same location, which supports integration of FCP into the established MSK pathway, while also providing greater mentorship opportunities for physiotherapists to upskill into FCP and advanced practice physiotherapy (APP) roles.
- Working as part of the wider MSK team helps FCPs to maintain their skill set in complex MSK assessments, mentorship and advanced practice techniques.
- There is less chance of FCPs feeling professionally isolated as they are integrated in a department with the physio and MSK teams.
For patients
- All patients in the PCN have access to the service five days per week, so there’s no need to wait for a specific day when the FCP will be in practice.
- Patients have access to an integrated team of MSK clinicians, which serves as a streamlined pathway to access MSK services, including physiotherapy, occupational therapy and podiatry.
For the PCN
- Confidence that patients are managed by an established team of MSK clinicians.
- Individual GP practices do not need to consider or find space to accommodate the FCP.
- Having a small group of clinicians offering the service means that the PCN is reassured that there is resilience, with clinicians covering each other during periods of leave/absence to provide the FCP service 52 weeks of the year.
- The group of named FCPs is small enough to establish meaningful working relationships with GPs and other members of the practices.
- There is integration of FCP within the practice team. FCPs, GPs and the wider team communicate regularly, using mutual shadowing opportunities, practice meetings and training sessions to build and maintain effective working relationships.
- The integrated service reduces duplication and improves the efficiency of care pathways
The qualitative patient feedback collected was submitted to the national phase 3 evaluation of FCP. It was collected during the initial FCP pilot from November 2018 to July 2019.
Next steps
In July 2020, the FCP offering in Erewash increased by 0.5 to two full-time FCP roles.
During the same period, DCHS expanded FCP provision to five more PCNs. This expansion was planned prior to Covid 19 and the team continued with the implementation and set-up to support primary care during the pandemic response. All of the new services have adopted the virtual first approach to reduce risk of infection transmission.
DCHS has been asked to double its existing FCP provision. The request has come from PCNs with established services who wish to increase the number of FCPs and from PCNs wishing to implement FCP for the first time. To accommodate this increased demand, DCHS is developing its existing workforce of physios and undertaking a recruitment campaign.
DCHS continues to adapt the FCP service models to ensure that FCP services best meet the needs of the population.
Key learning points
Suggestions
- The knowledge of administrators and their confidence in the FCP is integral to a well-utilised service. It is definitely worth spending time explaining the FCP role and scope of practice before implementing the service.
- Take a collaborative approach with the PCNs to understand their individual requirements and be flexible to adapt the service to meet their needs.
- Have regular, open communication with all members of the PCN team – particularly in the initial stages – to ensure shared understanding of the service.
- A single, shared, GP IT system and access to diagnostics is a great enabler of an efficient, integrated service.
Barriers and issues
- Initially, there was a perception that FCP should be provided from within the GP practice. However, we have been able to show the effectiveness and benefits of the hub model evidenced through patient feedback, outcomes and experience.
- It can be difficult to access existing diagnostic imaging for a patient who has previously registered with an MSK service. So it may be useful to develop links with radiology.
- Readying the workforce has been challenging. To support workforce development, DCHS has supported many physiotherapists with mentorship opportunities and training at local universities. DCHS continues to develop the team and recruit to support the rising demand for FCP.
More information about this case study
If you would like more details about this case study, please contact Susan Buckley, general manager of outpatient physiotherapy, occupational therapy and MSK services at Derbyshire Community Health Services NHS Foundation Trust.
