First contact physiotherapy study

First contact physiotherapy practitioners (FCPPs) have significantly increased in number in recent years, providing early access to MSK expertise within general practice. 

Implementation of the role differs across the UK. In Northern Ireland, for example, FCPPs are employed at band 8a and are required to have injection and prescribing competencies, whereas in the rest of the UK, most FCPPs are band 7 and are not required to have pharmacological qualifications. These contextual issues, along with other factors such as how the FCPP model of employment, levels of supervision, and their level of experience, can all impact the outcomes for patients and the practice, as well as the satisfaction levels of the FCPP.

Since its inception, FCPP has been subject to considerable local evaluation, which points to better outcomes for patients and improved resource use. A national evaluation of the pilot scheme in England in 2018/19, which followed patients for three months, indicated high levels of patient acceptability, reductions in pain scores, improvements in symptoms and quality of life, and high levels of confidence in the FCPP (Stynes et al, 2021). Amongst its recommendations for scalability, the evaluation recognised as a priority the need for more robust data-collection investigating the effectiveness of the role.  

The impact of FCP

The FRONTIER study was funded by NIHR Health and Social Care Delivery Research Programme to investigate the impact of introducing FCPPs into general practice, and to compare how clinical outcomes and resource use compared to GP-first consultations for adults with MSK disorders. GP practices and patients were recruited from across the UK, with patients followed for six months to track changes in their condition and any health and care resources they used. The team, led by Professor Nicola Walsh from the University of the West of England, was also interested in determining the impact of FCPPs with additional qualifications to inject or prescribe, so recruited practices that had FCPPs with and without these qualifications. As part of the study, the team also interviewed FCPPs, other practice staff and patients to help understand the benefits of the service and any challenges to successful implementation.

Significant benefits

The FRONTIER study recruited 424 patients across the UK and for the first time provided comparative data between GP and FCPP services, and different FCPP models themselves. The results showed that at six months there was no difference in clinical outcomes, irrespective of whether they consulted a GP or FCPP. 

At three months, however, significantly more patients had improved having seen an FCPP, meaning that more people got better sooner, which also positively impacted their ability to work. Very few patients who saw FCPPs subsequently consulted their GP for the same problem, whereas many more went back to their GP following their initial consultation. This means that FCPPs can reduce the MSK workload of GPs, allowing them more time to manage other conditions and more complex patients.

Results also showed that patients who consulted their GP had significantly more prescription medication, including opioid derivatives, than patients who saw FCPPs. This illustrates a further benefit of FCPPs and their potential to impact on the amount of prescription medications patients receive for MSK disorders. When the team looked at the difference between FCPPs who had the capabilities to inject and/or prescribe, there were no significant differences in patient outcomes compared to those FCPPs who didn’t have these additional skills. 

Cost analysis

The cost analysis provided a compelling case for FCPP models of care. Taking account of consultation and subsequent healthcare costs to manage the condition over six-months, there were significant differences in median costs per patient. For an FCPP without additional pharmacological qualification the cost was £41; for an FCPP with additional pharmacological qualifications it was £44 per patient. For GP consultees, however, the median cost equated to £105 per patient. This provides a significant cost saving for patients consulting with a MSK disorder only.  The cost analysis was based on band 7 FCPPs – but replacing this with band 8a still returned significantly lower costs compared to GPs. This analysis was based on a 10-minute GP consultation and a 20-minute FCPP consultation. For services that provide 30 minutes with the FCPP, this is still a lower cost return compared to the GP.

When asked about the results Nicola stated: ‘This has been a really challenging study to conduct as we wanted to ensure we involved all four UK nations, then we had the added complication of Covid-19 which meant we had to pause the study and restart under Covid restrictions. It’s all been worthwhile though. 

‘This is the first study to show the actual benefits of FCPP compared to GPs over an extended period. The expedited recovery alongside reduced resource use provides a really compelling case for FCPP-led models of care. The findings also show that there is no necessity for FCPPs to have the additional prescribing or injecting qualifications to achieve the same outcome.  This means the FCPP workforce increases won’t be hampered by physios having to achieve this before being appointed to FCPP roles, and this can be pursued as part of continued professional development, if required. 

‘It also shows that early access expert assessment, early diagnosis and appropriate advice are crucial, and for most people it is sufficient without pharmacological intervention or onward referral.’

The FRONTIER team also interviewed FCPPs, practice staff and patients to understand the factors that support successful implementation. The key issues were ensuring that patients were aware of the FCPP and the expert nature of the role and which patients they saw. Awareness and understanding were also essential amongst other members of the general practice team to ensure they discussed the role with patients and advocated for the service; all acknowledged that this took time as the service embedded and that early implementation led to challenges around who FCPPs saw. 

There was also considerable discussion on employment models. The CSP, on balance, supports the main service provider employment model, as terms and conditions are generally protected, governance and professional issues are managed centrally, and staff have a wider system understanding (HEE, 2019). Whilst most staff supported this approach, others reported that they felt less integrated into the team as they spent little time at each site, covering multiple practices. Staff employed directly via the practice or primary care networks considered themselves more integrated and embedded.

FCPP is an important development for our profession. Nicola added: ‘Local evaluations, along with the national pilot, established a strong basis for supported implementation. The findings from the FRONTIER study, however, provide definitive evidence of the importance of FCPP integration into general practice, and the significant benefits they have both for patients and the financially challenged health service.’ 

Chris Mercer, a consultant physiotherapist from University Hospitals Sussex

The FRONTIER study gives us really valuable data and insight into the acceptability and effectiveness of the FCPP roles. 

It’s really encouraging to see, not only the benefit these roles bring to patients and the system, but also that these benefits come sooner for the patient. 

Alongside these clinical benefits, the cost benefit analysis is also important as it helps support the financial case for these roles in the system.

It will be interesting to compare these results to other studies, such as the national CARPE study which is looking at a range of non-medical roles in primary care. 

The FRONTIER study also gives us a great foundation for future comparative studies.

For more information, visit the British Journal of General Practice.