Jehan Yehia, governance first contact physiotherapy lead for Kingston upon Thames in southwest London, illustrates how the borough has embedded FCP across all five of its primary care networks (PCNs) in the past year, while ensuring high standards of care among the FCPs who are directly employed by each PCN. Jehan is currently contracted by Kingston Training Hub.
Following a successful pilot FCP service two years ago, in May 2020, the Royal Borough of Kingston established the Kingston FCP model, which it rolled out to all five of its PCNs.
This model supports the NHS England Long Term Plan as well as its aim to include other allied health professions as part of PCNs' multidisciplinary teams.
Approach
There are five PCNs within Kingston. The FCPs are employed by the PCNs and a supervision and governance structure has been set up to assure the standards of the FCPs and support them on their advanced practice journey.
Each PCN has one full-time (band 7-8a) FCP, providing a service for between three and six GP practices, with their time divided according to the patient population at each practice.
Each PCN has an average population of 41,800, and the FCP provides the equivalent of 10 hours for every 6,000 patients.
Every FCP is mentored by a GP supervisor, and meets once a week with a musculoskeletal (MSK) supervisor who has completed the Health Education England supervisor training.
The FCPs have 80 per cent of their time allocated for clinical work and 20 per cent for non-clinical work, plus a 2.5-hour CPD session every month.
Set-up and implementation
Initially, the team consulted local stakeholders, using FCP guidance and resources from the CSP. Jehan had meetings with PCN directors, secondary care providers, the advanced practitioner network leads and practice managers.
Together, they wrote up a standard operating procedure (SOP) as well as a governance document, looking at how they would initially quality assure the FCPs for the practices. This document outlined MSK and advanced practice competencies, using the advanced practitioner competencies format. Once the first draft was developed, it was reviewed by the above stakeholders.
The documents have since been updated to align with the HEE's FCP roadmap.
As well as clarifying the standards of FCP that should be employed, the roadmap also outlines that this is the responsibility of FCPs and GPs.
The team then spent time developing its supervision model and understanding how it would work in practice. This evolved over time and was developed and changed as the first FCPs started in their roles.
The basic model consists of an FCP lead (Jehan) who oversees all the governance and quality assurance of the FCPs' MSK skills. Each practitioner also has a GP mentor who oversees their non-MSK and primary care development.
As part of the initial governance, each FCP has to complete six to eight workplace assessments (clinical observations) within the induction process and the level of practice is then relayed back to the GPs – this helps everyone to understand what level that practitioner is working at.
Having an FCP lead to focus on governance and quality assurance means that GP resource can be used elsewhere.
This set-up requires a lot of communication. The team holds regular meetings between all parties to keep on top of where the FCP is on their advanced practitioner journey, which provides another safety net for the FCP and the GP practices. At these meetings, they discuss the FCP's development in line with the HEE roadmap. These meetings usually happen at the induction, the six-monthly review and the annual review.
When recruiting FCPs, the team looks for physiotherapists with strong MSK skills, so that the transition to the world of primary care is optimum. The FCP is embedded within the GP practice and each FCP has a dedicated GP mentor, and the team has developed a CPD programme to help the practitioner transition into primary care.
Benefits
For staff and the PCN
- There is good integration as the FCPs are embedded within the practices, they are introduced as part of the GP team and they are involved in the clinical meetings.
- By having a physiotherapist as the physio lead, the GP's time is not taken up supervising the FCP.
- The GP mentor helps the FCP to better understand how the practice works and learn the thresholds for referrals. They are also a great learning source for the FCPs to develop primary care skills.
- The FCPs across Kingston work together as a team to share ideas, and discuss issues and MSK competencies. FCPs value this support and encouragement as well as having a space to share cases.
For patients
- The patients are not aware how the FCPs are employed, however feedback from having access to FCP has been extremely positive.
- The patients appreciate having access to physiotherapy advice at primary care level.
- They can access the services near to their homes without long waiting times.
- Patients are more likely to get the correct MSK resolution referrals quickly.
Outcomes
From an audit of 40 patients surveyed, the FCP service potentially reduced the need for 270 face-to-face consultations with a GP.
- 82.5% of the patients were seen once and did not re-present for the same problem
- 15% were referred on to an MSK service
- 12% were referred back to the GP for other management
- 12% were referred to a community physio
- 2 were referred for x-ray
- 2 were given a prescription
- 16% were given an onward referral
- 41% received social prescribing
Collected from a survey created using EMIS reporting software after the first three months of Jehan’s employment (January-March 2019), calculated by the GP surgery where Jehan was employed (Canbury Medical Centre).
Next steps
The borough succeeded in recruiting five FCPs working across five PCNs. The PCNs have found the process so successful that four of them are recruiting for a second FCP for their network.
The team is establishing an internal MSK academy and learning pathway to support FCPs through the FCP roadmap – most of them are going through the portfolio route. They are excited about this and are currently recruiting for likeminded experienced physiotherapists who would like to join their team.
They are also starting a process of standardisation, especially with red flags and safety netting, and are currently undertaking work to support the FCPs in primary care and improve patient care.
Key learning points
- You will learn as you go (and learn from mistakes), and the service will gradually develop, so it’s likely that the service will be very different to what you first envisioned.
- Work alongside GPs to embed FCPs into the practices, and understand what support the GPs require to set the FCP service up effectively.
- Implement structured supervision and governance structures that are permeable, so you can regularly update and modify.
- Autonomy and resilience are key to a good FCP service.
Barriers
There are sometimes barriers to communication with secondary care, especially since Covid-19 has impacted so greatly on secondary care. To overcome this, the team started conversations and teaching, and plan to develop shadowing opportunities for both sides (primary and secondary) to try to bridge the gap and improve the patient journey.
Isolation is a key concern for FCPs, and the pandemic has made some experiences more difficult, particularly for new FCPs who have been thrown into a new way of working. To overcome this, you should endeavour to stay in regular communication – for example, scheduling weekly catch-ups and daily sessions with the GP mentors.
More information about this case study
If you would like more details about this case study, please contact Jehan Yehia, governance lead FCP Kingston, FCP Canbury Medical Centre.