Robert Caine details how Betsi Cadwaladr University Health Board has enabled rural patients to access first contact physiotherapy (FCP) locally by integrating the service across 50 per cent of GP practices in the area.
Robert Caine is an advanced practitioner physio primary care lead for Betsi Cadwaladr University Health Board. As well as working as an FCP, Robert is also a lead clinician for FCP implementation and operation in the North Wales health board.
FCP was introduced to provide access to physiotherapy services in North Wales while also improving the patient journey, reducing the burden of musculoskeletal (MSK) issues on GPs, and ensuring more appropriate referrals to secondary care.
North Wales is rural and the population is widespread, with approximately 130 GP surgeries managed within 14 clusters. Therefore, providing FCP services in multiple GP surgeries was identified as the most sustainable approach, rather than having fewer ‘super surgeries’. This has reduced the need for patients to travel. However, it does mean that the FCPs must travel more between clinics.
Approach
As this is an integrated approach to FCP, the service is provided by Betsi Cadwaladr University Health Board, enlisting predominantly band 7s (with 8a as lead) to work within GP surgeries.
Some of the FCPs have a joint role, whereby they also work part-time in secondary care, which includes time in the Clinical Musculoskeletal Assessment and Treatment Service (CMATS).
As well as providing this first contact approach, the FCP service also acts as a gatekeeper to secondary care, identifying those who require or might benefit from secondary care specialist intervention.
There are 13 full-time equivalent FCPs, operating within approximately 50 per cent of the GP surgeries in North Wales, with each member of staff providing clinics 1-2 days per week.
Most FCP staff have non-medical referral rights for bloods and imaging, including MRI. Most are non-medical prescribers (NMPs) and injectors.
Set-up and implementation
In 2015, Betsi Cadwaladr University Health Board started out by approaching the Welsh Government to access funds from the pacesetter programme.
Following a successful application, Robert was appointed to develop the FCP strategy – to measure outcomes and evidence the success of FCP in improving GP capacity and reducing secondary care referrals and so on.
Pacesetter awarded funding to pay for one full-time, band 8a practitioner, which enabled the implementation, testing and growth of the project. The evidence was used to attract further funding (over the next 2-3 years) from GP clusters in North Wales.
To get the parties on board, Robert explained the benefits of the service at GP cluster meetings, hosted by the GP cluster leads, the GPs and practice managers, as well as health board managers.
The 50 per cent of GP practices who chose to offer an FCP service are those who were happy to fund it (they may have received funding from the Welsh Government) and those struggling with medical staffing.
All levels of care were involved in the implementation of FCP: the FCPs, physiotherapy leads, hospital managers, GPs, primary care practice managers and primary care support teams. And patient triage criteria were created to support reception staff to make referrals to the service correctly.
To manage consistency and quality, the FCPs work in line with key performance indicators dictated by the group and therapies team, as well as other standards set by the primary care managers and support teams who are also directly managed by the same therapy managers.
Benefits
For staff and the PCN
- Over 50 per cent of all GP surgeries in North Wales can facilitate FCP in-house, ensuring better access to the service.
- As the approach was developed holistically with most stakeholders/service providers, the team has buy-in from all parties and can ensure everyone is catered for and their standards are met.
- The approach allows FCPs to have more flexibility as they can dictate their own direction of travel. They decide how best to manage the service as they have the best insight into how to handle the MSK patient caseload in their individual GP surgeries.
For patients
- The approach ensures that the services are offered locally to patients, making FCP easy to access and regularly available.
- The service provision is adaptable and flexible to local needs (to an extent).
Outcomes
The team has achieved its overarching objective, which was to provide access to physiotherapy services in North Wales. However, it is very difficult to measure impact on GP workload and on referrals into secondary care.
The following positive outcomes have been evidenced:
- Less than 10% of patients seen are referred into secondary care MSK services.
- Less than 3% are referred for further investigations (x-ray, MRI, bloods).
- Less than 1% require a GP interaction for the same complaint.
- There are reduced costs compared with a GP providing the same service.
Next steps
The team will aim for better integration of FCP services with local CMATS as well as local government exercise initiatives, like NERS (a council exercise referral scheme in Wales), which would mean a patient's rehab could be completed with exercise professionals in a council-run gym. This would mean patients could access proper technical equipment if required as part of their treatment. Some patients could also be referred directly to NERS if it was a suitable option.
Integration into CMATS is already happening, although this is not always practical if staff work only part-time hours.
Key learning points
- Working with supportive GP staff and having a good relationship with them is imperative to the success of FCP implementation and management.
- It’s good to have a traditional GP model, whereby when a patient books an appointment, the GP then decides who they will see and whether an FCP is the most suitable option.
- Consider communications with the local community, so they understand the benefits of FCP for MSK ailments.
More information about this case study
If you would like more details about this case study, please email Robert Caine, advanced practitioner physio lead, Primary Care West, Betsi Cadwaladr University Health Board.