Right clinician, right place, right time: the role of the first contact practitioner from a rheumatology perspective

This editorial refers to ‘First contact physiotherapists: are they able to reduce the burden on rheumatology services? A critical review of the evidence base’ by Sarah Golding and Jo Jackson, 2024; https://doi.org/10.1093/rap/rkad109.

It is now a decade since the start of the use of a role that was then called ‘first contact physiotherapists’ and now is more broadly termed ‘first contact practitioners’ (FCPs) (1). These FCP roles were initiated to support the assessment and management of musculoskeletal (MSK) presentations in primary care. The role was envisaged to engage appropriately skilled and supported MSK clinicians to optimize the patient care pathway and to be a key part of an integrated care team in primary care [1]. Proposed outcomes included delivering person-centred MSK care at the first point of contact, enhancing supported self-management strategies, triaging and sign-posting patients more effectively for improved secondary care referrals and creating primary care capacity and wider system benefit [2, 3]. The FCP initiative is well backed, with the Chartered Society of Physiotherapy, the British Medical Association and the Royal College of General Practitioners recommending that FCPs be employed by incumbent providers of local National Health Service (NHS) MSK services [3].

In this issue of Rheumatology Advances in Practice, Golding and Jackson [4] present a critical review of the evidence base for the FCP role in rheumatology, while reviewing the emerging themes within the MSK field as a whole. Given the large number of FCPs funded and established in NHS primary care positions, this role must be embraced by those of us in rheumatology as we seek to improve the efficiency of rheumatology services with regards to incoming referrals [5]. Despite the dearth of application research found in the Golding and Jackson article [4], frameworks of practice for FCPs do demonstrate good representation of inflammatory condition screening [6], and the Rheumatology Physiotherapy Capabilities Framework [7] has a section of capabilities statements dedicated specifically to this role of FCPs, shown in Fig. 1.

Figure 1.

Screening in MSK settings: an extract from the Rheumatology Physiotherapy Capabilities Framework [7], with permission

Early detection of inflammatory arthritis leads to more rapid medical management in conditions where there is strong evidence of an optimal ‘window of opportunity’ to commence treatment to ensure the best possible long-term outcomes [5]. A growing number of clinicians are able to detect and screen for such diagnoses, and this is reflected by the fact that the latest version of the National Early Inflammatory Arthritis Audit includes a question regarding which clinician made the referral [8]. We need to understand how the role of the FCP is being integrated into our rheumatology pathways at an early stage.

The review of evidence by Golding and Jackson [4] highlights the requirement of FCPs to be appropriately skilled and experienced and that the renumeration for this role should reflect that advanced level of practice, describing Band 7 and 8a Agenda for Change pay scale roles associated with this. At initiation, the FCP role was created to place an advanced practice clinician in front of the MSK presentation in primary care [2]. There is concern that the current workforce in the FCP role, in reality, is prone to variation in application of this Band 7/8a model, with the potential for some services to recruit those without advanced practice skills [9]. By expansion of the arguments shared by Golding and Jackson [4], implementing FCPs without advanced practice may risk both missed cases and delayed diagnosis of inflammatory arthritis, as well as a potential for overreferral to already squeezed secondary care services.

Clearly the role of the FCP in primary care ties in with changes in access to rheumatology services suggested by recent BSR guidance [10], in combination with the push towards specialist advice, formally known as advice and guidance, and how we best triage incoming referrals in rheumatology [5]. Engaging stakeholders is critical to improving the abilities of rheumatology departments to deliver the care that is required, as well as supporting colleagues in primary care in providing assessment, diagnosis and management of patients whose needs are best met outside of secondary care rheumatology departments.

Featured in this issue of Rheumatology Advances in Practice, the Golding and Jackson article [4] confirms the emerging role of FCPs within rheumatology pathways in their frontline triage role that is crucial to ensuring that the right clinician is placed there at the right time to spot any early symptoms of rheumatology-relevant diagnoses. Although FCPs will be working across the broad MSK spectrum of conditions, they will undoubtedly see some early and undiagnosed rheumatology presentations. Acting as gatekeepers, screening out those who do not require secondary care rheumatology input is arguably as important as screening in those who do require it. In addition to further research into the outcomes of FCP input for early rheumatology presentations, the rheumatology community at large must engage this new primary care workforce in a proactive manner. Almost certainly, these FCP roles are established in a primary care setting near you; the evidence base supports such implementation, but we need to ensure as a group of rheumatology clinicians in a broader MSK community that this will prove to be a successful example of task shifting that delivers for primary care, for rheumatology departments and most importantly for the patients we look after.

Data availability

No new data were generated or analysed in support of this research.

Funding

No specific funding was received from any funding bodies in the public, commercial or not-for-profit sectors to carry out the work described in this article.

Disclosure statement: The author has declared no conflicts of interest.