Dr Neil Langridge shares his thoughts on contemporary issues as we approach PhysioUK 2021 in a focussed symposium that he is involved with on Advanced Practice in the UK.
I thought I would write a few lines regarding some reflections I have had concerning the FCP RoadMap (Primary Care Advanced Practice) (Acknowledgements Tim Noblet, Jodie Smith, Amanda Hensman-Crook, Julia Taylor, Matt Low) and the draft Advanced MSK standards across the multi-professions which I have also been involved in.
The prompts for this blog started with a short social media discussion that began with something along the lines of “what is the point of the FCP RoadMap standards? It doesn’t acknowledge experience etc, it’s a waste of time”, and secondly my observations of how a standards document can create battles which at the outset of developing the standards I was naïve about, and subsequently have learnt a lot over that time, and I hope it’s worth sharing.
Advanced practice as we know is developing very quickly. In terms of the MSK Roadmap to FCP and AP in primary care based on agreed standards and the pending advanced MSK standards have moved at a relatively rapid rate. The reason I say “relatively” is because prior to this we essentially had 25 years of slower development in this field. We had new roles, new job descriptions, variable accountability, but as a profession, no national level standards that would be considered agreed and transferable. I gained 22 years ago what was then described as an ESP role with an interview and locally agreed competencies which were signed off locally. There was no bench-marking of this, no central way of “judging” whether this process was robust, effective, fair, but as a profession we did not have anything else, and so in terms of Governance services were duty bound to produce their own. Some excellent work grew from (Syme et al 2013 APPN Resource Manual for Extended Musculoskeletal Physiotherapy Roles) this but it was not always shared, tested, or importantly required and so we all worked in silos with similar name badges, with minimal reference points between us other than implicit levels of practice that held a commonality through the term ESP, and through local needs which were non-transferable or recognised outside the organisation.
Consultant Practice emerged over 20 years ago, very little happened in terms of how to develop these individuals, how to bring them together in a common framework that would allow for the introduction of the title into the health system with the due reference to their skills and expertise, other than.. yep, the job title. How did I get my Consultant post? – through an interview, I believed at that time of my appointment (9 years ago) there was an enormous gap in how we justified these titles without any governance structure or capabilities underpinning them other than what would be locally agreed. I really experienced that when meeting medical colleagues who asked “so how do you get being a Consultant AHP?” I always felt I was scrabbling for a credible answer.
The Multi-professional advanced practice framework broke that process and settled the debate about what is advanced practice and certainly recognising it as a level 7 (masters level practice) and subsequently the Consultant Framework at Level 8 (Doctoral)was a significant line in the sand for Physiotherapy and AHPs to be able to consider aligning to this and getting houses in order to really drive the professions out of these silos into a much more aligned group with transferable standards.
When I initially moved into Primary Care in 2015, as a Vanguard pilot, the first observation I made was this is new and different, it’s not the exactly same as my physiotherapy practice, clearly based on it and influenced by my advanced orthopaedic roles, but importantly it felt different. I thought therefore that this had to be an opportunity to stop complaining about a lack of reference standards and do something about it. We thankfully had the MSK Core Capabilities framework to work with though and there could be no better time to build an agreed reference that would support clinicians, colleagues and services whilst assuring patients by offering a standard to work towards in FCP (Masters level) and advanced practice in primary care.
We needed to assess in practice the capabilities and competencies of these clinicians at masters’ level against these frameworks and this led to the MSK RoadMap in Primary Care which was built around capability, but also had the remit to bring together career opportunities and portfolio experiences into a common approach.
I knew there were local models already occurring for governance reasons, so we thought why not join them up into a national model? Many services were “operationalising” the Core Capabilities Framework, @Paulawoods5 (Paula Deacon), @simon_ingram13 (Simon Ingram) were good examples of how this was happening. The plan was to develop something that linked the frameworks already out there, multi-professional, MSK core capabilities and subsequently the advanced MSK standards into document so that clinicians when completing one capability could cross reference that across different pathways. This was felt to be one of the most important components; ensure that advanced MSK and FCP practice capabilities could be mapped and over-lapped where this happened so enabling a framework that could if wanted, cover both pathways. This would reduce work, offer depth and a pathway that clinicians could follow. Of course, FCP and MSK Physiotherapy are aligned in so many ways, and both needed to be on a pathway to advanced and consultant practice if clinicians so desired this.
Support was offered from HEE and with other groups such as the MACP, APPN, SOMM and what is known as the MSK partnership as the building of this occurred. At the same time there was a real drive on standards and governance from MSKR and I met kindred spirits in these groups and Connect Health @ashjamesphysio (Ash James) who were supportive throughout.
Finally, a primary care standard was agreed, the Advanced MSK standards are now pending and the Consultant Framework will need to have doctoral level MSK capabilities attached to it as we move forward.
As I reflect on this I also return on the statement “it’s a waste of time”. My view still remains that if so, what is the alternative? I have seen these standards create quite differing reactions from organisations who from what I see and experience had agendas that were not either clear to me, or were in opposition to what we were trying to do. This is where much I my naivety became rapidly apparent. Incorporating standards – my narrow view was, “of course we should all want that, I bet patients would want that, and for career profession, and ultimately patient safety, it’s a must”. Then out of this somewhat blinkered thinking of mine, the drivers/barriers to this began to rear their heads.
Contracts, money, banding, staffing. I assumed that standards come first and then you work the rest around that, however it soon became clear that I may have mis-understood the relationships that occur when agendas are challenged.
We ran I into the debates on how FCP will de-stabilise services, that we will lose clinicians, that achieving standards will take too long and quotas won’t be reached, which I understood entirely, I didn’t necessarily agree with but I had already written about this problem back some years ago (circa 2001):
….but as we move to managing populations and integrating care, the de-stabilisation argument does not in my opinion come from the clinical concept of FCP, but the logistics and operationalisation of the model itself.
This is now where I see the gaps across advanced and FCP practice. There is no value in identifying the gaps and then not offering an alternative and so thinking what next is the key question. The health system we have is cut up into “pockets” but being brought back into “systems” once again that ultimately can provide care at scale across all pathways.
I feel there is a disconnect between application of standards, professional development of practice and system readiness to accommodate the rapid growth. What I fear is that whilst the profession rapidly works into these new spaces is that firstly patients are not informed with regards what these roles are, they are the advocates the profession should be working under. Secondly the system destabilisation suggestion is not FCP but the method in which it is being allowed to be provided. Individual models that lack integration due to contractual obligations and/or models that don’t promote the integration as a central requirement ultimately are providing contracts for providers at the expense of the pathway, and not really supporting the whole MSK system as much as it could.
This is the time I believe for MSK services to link together, halt being driven into competing contracts, and bring the best of each service (FCP, Interface, Rehab) under good quality leadership, that provides exciting, blended roles. If we have this the barriers I experienced as I saw the Primary Care standards emerge will be managed by joined up, co-produced leadership across a system. If we want to stop the belief that we are de-stabilising MSK services then join them up, economy of scale, re-invest the savings of this model into staffing, recruitment, retentions, and training and build the workforce around the standards and not the other way round.
This then has to be topped off with an agreed career framework for all MSK clinicians working to the same standards, with the same opportunities, whether its sports rehab, therapy, ex instructors, Physiotherapists, if they map to the standards, then they can do the job. Invest across the system and it will offer greater economic development, invest at scale into blended roles, invest in quality and standards, and I believe this ensures it is not waste of time, standards actually are how you stabilise the systemand create a model of growth that patients will benefit from.
So, if we have standards, we now have to create the environment for them to flourish in for the benefit of patient care. It is my belief as advanced practice and FCP emerges that the leadership now is vital, and this must not be at the expense of awarded contracts that do insist on integrating and effecting a wider change rather than just seeing a case load. System management/leadership, blended roles, MSK roles across all professions, integrated population management pathways, contracts that allow for growth and not suppresses it are some ideas that have crossed my mind of late, what do others think?
What I have learnt in my naivety is that without a system change that is symbiotic to the development of standards then patient education, higher education, professional groups will struggle to meet so many differing demands and the full benefits of these changes may struggle to be realised.
Dr Neil Langridge, APPN President, MACP Vice Chair and Education Lead (FMACP, FCSP)