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[Physio Explained] Behind the scenes of a first contact physio with Helen Welch

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In this episode with Helen Welch we explore some of the complexities in Primary Health Care. We discuss:

  • Role of a first contact physio and the types of patients they see
  • Expectations of First Contact Physios (FCP’s)
  • The importance of managing these patients in a holistic manner
  • Burnout and the impact of this on FCP’s 
  • How to get involved as a FCP

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Helen Welch is a consultant MSK physiotherapist and First Contact Practitioner (FCP) lead in the West Belfast Federation, where she oversees advanced MSK assessment and management. With extensive postgraduate training, Helen is a non-medical independent prescriber, qualified in joint and soft tissue injections, and a CASE-accredited MSK sonographer skilled in ultrasound-guided interventions. A former Chair of the Musculoskeletal Association of Chartered Physiotherapists (MACP), Helen has played a key role in shaping national MSK practice standards through her leadership in the UK MSK partnership group.

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UNKNOWN:

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SPEAKER_02:

So how I like to see it, it's really looking at the biological, psychological and social aspects of that healthcare within that patient's consultation. So you have to be really holistic, which adds to the complexity because it's really, you're not just dealing with a simple outpatient sprained ankle. They might come in with significant social care aspects that you have to take into care. We know that the population is ageing. So you've got multiple comorbidities, multi polypharmacy in an ageing population. That all adds into the complexity of patients that we're seeing.

SPEAKER_00:

Welcome to another episode of Physio Explained. Today we're exploring the world of first contact physio with none other than Helen Welch, consultant MSK physiotherapist and FCP lead for West Belfast Federation. Helen brings frontline expertise in managing MSK conditions in primary care with advanced training as a non-medical prescriber, injection therapist and case accredited MSK sonographer. She's been a key voice in shaping the profession from her leadership as former chair of the MACP to co-chairing the UK MSK Partnership Group, where she led the development of the National Advanced Practice Standards. Helen also lectures on postgraduate MSK programmes and is currently undertaking her professional doctorate focused on complexity in primary care. In this episode, we unpack the FCP role, the types of patients commonly seen and what makes cases complex and how we deal with complexity. We explore what drives that complexity and importantly, the the factors that are modifiable with complexity. So if you're working in a FCP or considering an FCP role, this conversation is essential listening. You're going to really love this one. I'm James Armstrong, and this is Physio Explained. Helen, thank you so much for joining us. It's great to have you on the PhysioExplained podcast today. Thank you, James. Nice to be here. So today we're talking about the ever-expanding and interesting world of FCP, so the first contact practitioner that we often are seeing a lot of more clinicians moving into now. Today we're going to talk very much about the complexity of the role and what the FCP practitioner may see. So to begin with, can we start with just a bit of an overview of FCP and the types of patients these clinicians see?

SPEAKER_02:

So we know first contact physio practitioners have developed organically almost from extended scope roles which have been in physiotherapy since the early kind of 1980s and they're really in a response to the demands that are growing in primary care both from an ageing GP population and the fact that we need to have intervention earlier in the patient And there's always that reference that comes out that 30% of the patients that are seen in GPs are musculoskeletal in nature. So as a musculoskeletal expert kind of healthcare profession, which is physiotherapy, is in part, it seemed an ideal place to put first contact physios in there. Now, some of the issues that have arisen as it's organically developed is that hasn't developed. consistently across the four nations in the UK. So we've seen variations in terms of banding, variations in terms of actual healthcare providers, whether you're a private provider, trust employed or a GP cluster federation employed, variations in terms of ratios of number, so physio sessions per whole time equivalent, number of practices that you're meant to cover and your kind of banding and supervision structure. So you've got that level of variation as a physio thinking about going into an F first contact physio role is really having an awareness what actually your expectations are within that role that you're going into, which is often hard because of that lack of consistency across. You can't say that what you might expect in one area is the same as what you will expect with the other. It is hard then for clinicians to opt for a career that they might enjoy or they're in a situation where it hasn't lived up to their expectations and that increases the complexity and some of the stress that clinicians are feeling in these roles.

SPEAKER_00:

And we're hearing that about that, aren't we, a fair amount in terms of burnout in this role and maybe some of that is to do with the lack of accurate expectations with people going into these roles.

SPEAKER_02:

There's research out there that definitely has reported that the management of complexity and the clinical uncertainty in primary care does affect GP recruitment and retention rates and as FCPs move into this role it's not surprising that we're seeing the same effect in first contact physios as we would see within our GP colleagues. It's then how do we modify that situation to try and make the job not so much easier because that's probably the wrong word but more achievable for the physiotherapist to increase the life expectancy of the role because We have heard anecdotally about physios leaving first contact roles and returning back to an MSK setting. And it would be interesting to really sit down and explore what are the main reasons for that within the profession and what can we do to address those further.

SPEAKER_00:

You talked about complexity, Helen, and it's something that I'm sure a lot of listeners are aware of. It can increase quite dramatically in the first contact physio role. And we talk about managing complexity. Can you talk to us a little bit more about the complexity that is seen and how that's managed within the FCP role?

SPEAKER_02:

I think when you talk about complexity and you look in the literature, although it's a concept used frequently within the healthcare setting, it's got no standard definition. So it's really based on both your own personal experiences and your own personal scope of practice as a physiotherapist. Often the clinical setting that you're in and the socioeconomic demographics of the patients. So it is really multifactorial, which is then hard to put it in a definition. So how I like to see it, it's really looking at the biological, psychological and social aspects of that healthcare within that patient's consultation. So you have to be really holistic, which adds to the complexity because it's really You're not just dealing with a simple outpatient sprained ankle. They might come in with significant social care aspects that you have to take into care. We know that the population is ageing. So you've got multiple comorbidities, multi polypharmacy in an ageing population that all adds into the complexity of patients that we're seeing. We're also dealing with complexity. And again, this is as a result of kind of the wider healthcare system we know that patients are waiting longer for that secondary care opinion and in primary care you don't have the luxury of discharging patients you know you are their main port of management your door is always open for that patient to come back so sometimes your role is not only assessing and treating the condition and signposting them onto management but but managing their expectations and trying to meet the expectations of a healthcare system that might not be robust enough to meet the needs of the individual patient sitting in front of you. It's all those factors that come together to make that complex and really increases the demands within the patients and makes it really a challenge when you go out into FCP roles, but also an opportunity that you can, for some of those patients, spending time and listening to them and addressing their problems earlier in the patient care journey and being more holistic and understanding the community from where they've come to and the resources that they can embed into in the community does provide some valuable contribution to them. And you do see some real changes with patients when you kind of see them in the more holistic nature. But going back to your point in terms of that complexity that is seen. So if you think about 30% is MSK problems and when first contact physio was first promoted, it was to reduce the burden on the GPs for them to see the more complex patients. Now that makes the assumption that MSK patients aren't complex. And both from myself and your experience, know the complexity that is within an MSK. For

SPEAKER_01:

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SPEAKER_00:

Absolutely. And that's the complexities. I think sometimes when, I don't know, I think I have done it, is looking at the FCP role, you think the complexity is all going to be in terms of the condition you see and the unpicking diagnosis and the biomedical management of a patient. And as we spoke about off air, it's actually, it's the other stuff. It's actually how you deal with these patients on a wider spectrum and all the other things that come along with it. So looking at the influences of complexity, what sort of things, and I'm thinking also from the clinician's point of view, as well as the types of patients, what are the influences around complexity?

SPEAKER_02:

I'm currently doing my professional doctorate, looking at the experiences of management of clinical complexity in primary care within a Northern Ireland setting. And I think it goes back to say, you can never remove clinical complexity from your caseload. You are always going to get a patient that comes through that you may not be able to explain or provide a diagnosis within your level of knowledge. You cannot know everything about every condition that comes in and that's where we talk about the modifiable factors that can influence the complexity that you see. So you've got the complexity within the patient and the complexity within the clinical consultation. So what I mean from the clinical consultation in the clinical setting is if you have a really good support network. So if you have the GPs within the practice that are invested within the first contact physiotherapy service and have an open door policy where if you get complexity, you can knock the door and answer that clinical question so you don't have to worry and you can deal with that patient adequately by knowing your scope and using your your medical professionals appropriately. The other thing that has come out from the research is the time. And some of the research that came out with the CSP found that a lot of first contact physios think that the time that they're giving with the patient, although generous in the eyes of their GP colleagues, is often too short a time for them to fully address the complexity of the patient and that biopsychosocial aspect. So you've got a variation of some people are running to a 30-minute appointment. Some people are running to a 20-minute appointment. So to fully address all that patient's needs, do a thorough assessment, address their polypharmacy, their multiple comorbidities and their patient expectations, that's a push within 20 minutes. So you do need to restructure your clinical assessment from a traditional model that you might have used in MSK, from, again, getting that definitive diagnosis to managing risk. So understanding that you might not have a diagnosis, but as long as you've managed the risk and ruled out the serious pathology, then the story can evolve as you go on. The other thing that I'm really interested in is something that they've done a lot of work on for medical colleagues is your inherent belief system and your cognitive reasoning, which makes you able to manage that risk and that clinical uncertainty a little bit better. They've done some kind of research on GP colleagues and medical professionals in a secondary care and they've basically said that it's the clinician's own internal belief system which has a role within the reasoning and your subsequent level of stress and anxiety. So kind of your emotional, your ethical, your clinical reasoning, your view of the world will help you manage that clinical uncertainty and that diagnostic risk which makes you a better person to take on an FCP role where research would suggest if you're more biomedical in thinking that you don't do very well in a situation which its cornerstone is undifferentiated diagnosis.

SPEAKER_00:

And I think that's a really interesting point and we're going to finish on another question in a minute Helen but I think that's key isn't it in terms of that personality type and we mentioned you know sometimes you just you get a feeling of when someone is going to be right for an outpatient setting and in this this personality that that comes through you've kind of mentioned there that they need to be ready for that uncertainty ready to manage risk and not necessarily have an answer all of the time or even most of the time

SPEAKER_02:

it's okay not to have an answer some of the conversations i've had as part of my research one question i asked was were you prepared for for the fcp role did you know what to expect and the majority of them weren't and they have found almost through that baptism of fire that they have changed in the five years since fcp has been implemented so their clinical reasoning model has changed they have defined and worked more closely with their scope of practice they've worked hard to maintain the relationships that they had in a secondary care setting with the orthopedic team but bringing on those And they talk about a spectrum of complexity to patients that are difficult to manage, which are your chronic pain patients that have maybe those social care aspects and those psychological and those mental health needs that might take multiple referrals and multiple professionals to get involved, that are complex to manage because of the difficult nature of their presentation. which is different than the cases that are clinically complex in the fact that they don't know what's wrong with that patient and they need to seek advice and assistance. because you're more sure of your own role and your position within the primary care environment but that's taken four or five years for a lot of those clinicians to get there.

SPEAKER_00:

Yeah absolutely yeah it's an evolving practice and when you evolve yourself as a clinician and and I've heard many a story of many of my colleagues who've gone into FCP roles who've said it's really changed them as a clinician and fast-tracked a lot of their knowledge and it's been a real eye-opener for many of them. I thought it'd be really nice to finish the episodes Helen just in the few sort of 30 seconds or so we've got left with some a bit of a bite says because there's a lot of great things about the fcp role in terms of what it can open up for physiotherapists so anyone listening to this who's thinking about dipping their toe in the water of fcp and investigating it as a possible career what tips have you got for those people listening

SPEAKER_02:

it's a question that i asked everybody's part of my research what would they advise somebody coming into this role if they felt unprepared for this what would help somebody be more prepared and what they felt was really useful for anybody coming out to this role is to spend time with the FCP in the area that you want to work because there's that variation between different settings and between different health boards or trusts or CCGs. It's spending time with the FCP and getting a flavour of the workload and the expectations of that role within that clinical setting and I've signposted most of my band six MSK staff to do the preparation e-learning for health modules that were developed as part of the NHS England roadmap. They're a good foundation in terms of knowledge. There are also some good foundational courses out there that focus on the skills that possibly weren't touched on as much within your formal physiotherapy training. So certainly integration of blood tests in terms of that undifferentiated diagnosis is really useful. We spend some time looking at recognition and management of inflammatory arthropathies, because again, we know that people can wait nine years for a definitive diagnosis. So if we're targeting them early in first contact physio, we're making a big difference. We also spend a lot of time looking at your consultation skills. So changing that hypodeductive clinical reasoning to more of a narrative ideas, concerns and expectations model, which is really useful to start to introduce earlier.

SPEAKER_00:

Wonderful. Helen, thank you so much for your time today. It's been really, really useful and a very thought provoking, I think, for anyone listening who is either thinking about or is in, I think, even an FCP role. So thank you once again, Helen, for your time today.

UNKNOWN:

Thank you.