Principles of first contact physiotherapy: a resource to support service evaluation

How to use this resource

This resource will support FCP services to identify what is working well and areas for improvement. It describes the fundamental principles that underpin effective and sustainable FCP services. Each principle is explored in some detail to demonstrate how it might look like in practice. These descriptors allow for variation in service design, which should reflect local strategic priorities and local population need.

We would encourage all FCP services to undertake an initial service evaluation against the principles to highlight the areas which could then be developed using quality improvement methodologies. Although many of the principles interlink, this resource can be used over a period of time or in sections depending upon local priorities and capacity. It can also be used in conjunction with other national or regional work relating to areas such as advanced practice, workforce planning and education commissioning.

FCP services are integrated within the surrounding MSK system

What does this mean?

• Integrated services mean patients see the right person, right place, right time
• System leadership is evident to support integration and pathway transformation
• FCPs work with primary care team colleagues and other parts of MSK system, and not in isolation
• FCP and MSK interface services collaborate to ensure the services are complementary and maximise referral management
• Clear, streamlined pathways, designed with the patient at the centre, are in place and followed e.g. into MSK interface services, secondary care etc.
• Appropriate processes are in place to:
  - support communication between clinicians across the pathway to ensure access to clinical support as needed
  - facilitate data sharing and flow between linked local services*
• Systems are developed to ensure continuity of care for patients
• Processes are clear to ensure the FCP model remains focused on diagnostics and first line intervention
• Benefits are realised and evidenced across the system e.g. improved secondary care conversion rates, appropriate physiotherapy referrals, use of diagnostics optimised.  The wider system subsequently supports and invests in FCP.

^{*see FCP data and evidence FAQ}

What might this look like?

• FCPs are employed by the incumbent MSK provider.  Where this isn’t the case, clear steps have been taken to ensure integration

• Partnerships exist between commissioning bodies, GP practices, providers and FCPs (including secondary care and independent or private providers), relating to management, supervision, training and future workforce development etc.

• FCPs have the same referral rights as GPs (as a minimum) into:
  - diagnostics
  - locally commissioned community services
  - secondary care services e.g. interface

• Implementation is done in a sustainable way through system transformation, if required

• All involved have a clear understanding of the system and its stakeholders, including the wider MSK and other local healthcare systems

• FCP services complement the existing MSK pathway and are not a ‘bolt on’

• MSK physiotherapy workforce is considered from a system perspective. Roles are designed to avoid destabilising existing services through implementation that is not integrated

• Clear communication channels exist within and across the MSK pathway, and other appropriate pathways including Advice and Guidance if available

• FCPs take part/lead multi-disciplinary management processes across primary, community and secondary care as required, to enhance patient care

• IT systems are integrated or aligned

• Integrated pathways exist with other MSK services such as triage, to ensure duplication does not occur

FCP roles are located and embedded within a multidisciplinary primary care team

What does this mean?

• Regardless of employer, FCPs should feel and be an integral part of the primary care team, routinely working with practice colleagues*
• Clear roles/responsibilities and strong communication channels exist between the team
• The primary care team understand and support the role, responsibilities and offer of FCP, including how this differs from a ‘practice physiotherapist’
• The FCP is connected with appropriate teams/services along the MSK pathway*
• FCP services bring additional MSK expertise into general practice
• GP MSK workload is reduced with increased primary care capacity created
• Clear governance structures are in place within the primary care team to ensure patient safety*
• Where FCP is delivered virtually, this service design is based on population need and agreement between primary care and providers
• An in-person option is part of the service offer in order to support personalised care and shared decision making between the clinician and patient
• Evaluation data is used to measure success and/or challenges to services*

*see FCP lessons learned: discussion with an FCP service and FCP standardised data collection

What this might look like within the primary care team

• FCPs are co-located within practice settings, are involved in GP education sessions, practice meetings and other practice ‘events’
• FCPs are as easily accessible as GPs and do not operate waiting lists
• ‘Open door’ policies are in place for easy access to GPs and multidisciplinary colleagues with routine access to case discussion meetings
• FCPs lead training of the practice team to upskill in MSK care
• FCPs are involved in appropriate multi-professional supervision
• Administrative staff receive regular training to ensure correct care navigation*
• Robust induction processes are in place*
• An MDT approach (both within primary care and across the pathway) for individual patients is supported and available when indicated
• FCPs deliver sufficient sessions within one practice to allow embedding to occur

*seeFCP care navigation guide & FCP induction checklist

What this might look like within the pathway

• There are good links to local MSK services with cross-system mentorship/supervision/training for governance
• Opportunities exist to access local physiotherapy/interface in-service training
• Local/Regional communities of FCPs are developed to provide peer support regardless of employer*

*see FCP peer network directory

FCPs create primary care capacity and wider system benefit

What does this mean?

• FCP services create primary care capacity, achieving a positive impact on MSK conditions and general health
• GP MSK workload is therefore reduced creating capacity to see other patients
• Embedded, integrated FCP services are likely to have greater impact across the system than those who work in isolation from others in the pathway*

*see FCP national evaluation results

What this might look like:

• FCP service data is routinely collected and reflects impact in primary care and across the wider system through metrics such as; use of diagnostics, conversion rates, appropriateness of onward referrals
• FCP services are commissioned to provide sufficient sessions to demonstrate impact, based on knowledge of population needs
• FCPs are co-located in practice settings or embedded within hubs. When a hub approach is adopted, clear steps are taken to ensure the FCP remains integrated with all practices linked to the hub
• Maximum impact relies upon integrated and embedded systems/processes and knowledge, skills and attributes of the FCP
• Population-health focused-FCP services will have greater impact on the wider health and wellbeing of the practice population, thereby reducing primary care demand

FCPs offer an advanced level of clinical practice

What does this mean?

• FCPs work at an advanced level in the clinical pillar of advanced practice (AP), at a minimum, with many working toward or at AP level across all four pillars
• FCPs provide safe, high quality assessment, diagnosis, self-care advice +/- first line management and onward referral as appropriate, at the start of the patient pathway with appropriate management of red flags and underlying serious pathology
• FCPs work at a standard of practice and governance to provide quality care that improves patient outcomes
• FCPs contribute to the development of others through supporting students, MSK physiotherapists who may move into FCP roles in future, other FCPs and multi-professional colleagues through appropriate training and supervision
• Appropriate governance structures are in place to ensure patient and FCP safety that align with Health Education England’s (HEE) ‘First Contact Practitioners and Advanced Practitioners in Primary Care: (Musculoskeletal) A Roadmap to Practice’ (subsequently referred to as ‘Roadmap’) in England or country AP/career frameworks*

*see HEE Roadmap to Practice, Framework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales, NI Advanced AHP Practice Framework, Scotland NMAHP Development Framework

What this might look like:

• In England, FCPs are able to demonstrate academic master's (level 7) capability in line with HEE’s Roadmap to Practice. Supervisors will be trained locally with the support of primary care training hubs. Services and systems have plans to support their workforce to complete the Roadmap
• FCPs are seeing patients with a range of complexities, as a true ‘first contact,’ seeing undifferentiated MSK presentations and undiagnosed conditions as the first point of contact
• Many FCPs will have additional clinical skills including injection therapy and independent prescribing but this is not a prerequisite for the role
• FCPs are able to demonstrate; advanced MSK systems-based complex clinical reasoning, communication, personalised care, critical thinking skills
• Sufficient time is allocated within job plans for appropriate supervisory requirements, training and CPD e.g. 70:30/80:20 split, dependent upon role, to ensure capability is developed/maintained
• Appropriate debriefing and supervision processes are in place to ensure FCP and patient safety
• Training opportunities are developed and funded in response to local workforce need, with plans for workforce pipeline supply in place across a pathway
• Student placements and rotations are developed across the MSK pathway that include FCP services

FCPs offer a population health approach

What does this mean?

• FCP utilises a population health-based approach
• Systems should consider the needs of their population when determining FCP coverage
• 49% of patients consulting an FCP have a co-morbidity. FCPs need to be able to manage MSK conditions within this and other contextual factors*
• Links between lifestyle and musculoskeletal health in relation to primary (preventing conditions) and secondary prevention (preventing conditions getting worse) are promoted by the FCP to patients and colleagues
• FCP services are mindful of the whole range of determinants of health and wellbeing with the resulting health inequalities that arise*
• FCP services improve the physical and mental health outcomes, and wellbeing of people within and across a local, regional or national population
• FCPs engage with and contribute to the assessment of health needs within a community

*see Phase 3 national evaluation resultsand My role in tacking health inequalities: a framework for AHPs

What this might look like:

• FCP services are designed based on local population health data and mitigate the risk of increasing health inequalities*
• FCPs have the training and skillset to deliver a population-health approach, informed by local population health data
• Evaluation data is used to understand local population health need and enhance service delivery
• FCPs appreciate their own role in population health and reflect this in their practice e.g. deliver a range of public health messages, support behaviour change and change health beliefs. Mechanisms are in place to ensure this is happening e.g. embedded into clinical templates
• FCPs routinely have conversations with patients about staying in or returning to work, appropriately using the AHP Health and Work report to facilitate return to work. This should be recorded and measured at a local level
• FCP services empower patients with the knowledge to self-manage and improve their own health within the context of their co-morbidities. They make best use of digital options available
• FCPs use the assets of the local community, linking with other services across the wider local public health system e.g. social prescribing, community physical activity initiatives
• FCP services take into account local geography and any associated access challenges to their services

*See NHSX MSK Digital Playbook 

FCPs offer a personalised care approach

What does this mean?

• People have choice over how their care is planned and delivered to achieve improved health and wellbeing
• FCPs support people to stay well and make informed decisions and choices through shared decision making when their health changes
• FCPs empower people to build knowledge, skills and confidence to live well with their health conditions
• FCPs actively address local health inequalities

What this might look like:

• FCPs have sufficient training, knowledge and skills to deliver personalised care
• FCPs integrate shared decision making into their practice to ensure what matters to the person is core to the planned outcomes of care
• Approaches such as health coaching and patient choice are integrated into practice to increase patient activation
• FCPs develop strong links with; social prescribing services, community providers, self-management education support or other local resources
• FCPs make best use of available digital resources being mindful of not compounding health inequalities and preserving patient choice

FCP services deliver good patient experience outcomes

What does this mean?

• Enhanced, shortened pathway for patients with appropriate referrals at the appropriate time, avoiding duplication
• Patients access expertise early and in a location usually closer to home
• Patients are involved in decisions about their care through shared decision making
• Patients report positive experiences

What this might look like:

• Services routinely access or develop self-management resources and remain engaged with their local offer
• Services routinely collect PREMs and use these to undertake continuous improvement cycles
• Consideration is given to how PROMs can be developed to capture outcomes for patients using FCP services as part of the MSK pathway
• People with lived experience are involved in co-designing services and there is engagement with local external patient groups
• FCP services are promoted locally to reach a wide range of patients, with awareness of local health inequalities*
• Local services aim to achieve a high level of patient understanding of the FCP model, in order to set clear expectations

*see GP reception materials 

FCP services deliver good staff experience

What does this mean?

• FCPs feel they are a valued member of the primary care team with appropriate support, supervision and CPD opportunities reflected in an agreed job plan*
• Support is given to fulfil Roadmap requirements or the country specific advanced practice framework

*See NHSEI job planning guidance 

What this might look like:

• FCPs have sufficient length of appointments, minimum 20 minutes, but may be longer to suit local population and individual clinician requirements*
• FCPs are encouraged to develop, support or join local or regional peer networks to ensure FCPs feel part of a community of practice*
• Job plans account for travel time and include adequate non-patient contact time for; CPD, supervision, mentoring and sufficient admin time etc.
• Blended or portfolio roles are offered across other parts of the MSK pathway with opportunities to progress to an AP role if desired
• FCPs stay in post with ‘normal’ rate of staff turnover and report high level of job satisfaction
• Line managers have frequent individual discussions about FCP wellbeing, alongside regular data evaluation to capture FCP and MDT staff experience

*See Implementation Checklist and FCP Peer network directory