The MSK training pathway to First Contact Practitioner and Advanced Practitioner in primary care

Amanda Hensman-Crook

For the first time, primary care has a standard of practice for MSK for diagnostic clinicians. The development of a career pathway using an educational training roadmap to work in Primary care at Master’s degree level, (supported by specific supervision) is now in place to ensure the quality of care from the start of the patients’ journey with MSK conditions.

The NHS Health Education England resource ‘First Contact Practitioners and Advanced Practitioners in Primary Care: (Musculoskeletal) A Roadmap to Practice’ can be found at:

www.hee.nhs.uk/sites/default/files/documents/A%20Roadmap%20to%20Practice.pdf.

What is First Contact Practitioner (FCP)?

A First Contact Practitioner is a diagnostic clinician working in Primary Care at the top of their clinical scope of practice at Agenda for Change Band 7 or equivalent and above. This allows the FCP to be able to assess and manage undifferentiated and undiagnosed MSK presentations.

It is the minimum threshold for working as a first point of contact with undifferentiated undiagnosed conditions in Primary Care. With additional training, FCPs can build towards advanced practice.

To become an FCP, recognition is required through Health Education England, whereby a clinician must have completed a taught or portfolio route.

FCPs work at master’s level (QAA level 7) in their clinical pillar of practice but have not yet reached an advanced level in all four pillars of practice to be verified at AP level across all four pillars.

The clinician must have a minimum of three years of postgraduate experience in their professional specialty area of practice before starting Primary Care training to become an FCP.

FCPs refer patients to GPS for the medical management of a patient’s condition with non MSK presentations and pharmacology outside their agreed scope of practice.

How does the model work?

Figure 1: High Impact Investigations First Contact Practitioner for MSK Interventions 2019 NHSE and NHSE/I

What is the educational training pathway?

Figure 2: First Contact Practitioners and Advanced Practitioners in primary care (Musculoskeletal) HEE

Once clinicians have been registered post HEI training, as novice practitioners they are encouraged to work across all specialities (neurology, medicine, respiratory, paediatrics, orthopaedics, rhumatology etc) and across all healthcare settings for two years. This is to build a broad base of knowledge in practice within and outside MSK and to learn multi sytem care pathways across all settings.

Following this, and now in MSK, they continue to develop across the MSK spectrum and move from a novice to experienced clinican over a minimum of three years prior to commensing prmary care training. This time is spent widening their MSK learning across MSK specialitites, and consolidating understanding of how their wider knowledge of other conditions and pathologies can be drawn into one clinical consultation to effectively manage the presenting condition.

It is essential for clinicians to have this firm foundation when working with undifferentiated and undiagosed conditions in primary care. All clinicians need to have the ability to rule out red flags and visceral masqueraders, and detect early serious pathology at the first point of contact. They must also have a good understanding of local care pathways including two week waits.

The aditional primary care training typically includes radiography, MSK bloods, injection therapy and prescribing as well as developing the ability to work with complexity and medical uncertainty. FCPs have the same access as GPs to diagnostic services and onward referral into secondary care, so it is important that these capabilities are assesed and verified to the right level of practice.

It is also important to note that although MSK First contact practitioners have a focus on rehabilitation providing exercises and advice for MSK conditions pre and/or post operatively, they do not ‘treat’ patients. This service is provided with an onward referal into core physiotherapy or other rehabilitation services as required.

How does FCP impact on orthopaedics?

National evaluation has shown that the referal to orthopaedics from FCPs is low (average of 2.9% of MSK caseload) with a high conversion rate to surgery.

The Phase 2 national evaluation of First Contact Practitioners showed up to a 56% reduction regionally of referal to orthopaedics from primary care.

Further information can be found at: http:// arma.uk.net/wp-content/uploads/2020/05/ FCP-MSK-review-with-authors_v3.pdf.

FCPs prepare patients with an explanation of the pros and cons of possible surgical interventions pre referral to orthopaedics, and review post-surgery to ensure that rehabilitation is maximised and to identify any early complications should they arise post-operatively.

Conclusion

By setting a standard of practice for MSK in primary care, it guarantees capability and expertise at the front of a patient care pathway which streamlines MSK patient care across the whole healthcare system providing a gold standard of care for this patient cohort.