Clinical governance is a mysterious concept to many. My practical understanding, after spending a decade in the NHS, was mixed. The importance of clinical governance is fully embedded in the clinical psyche but its tangible elements are more difficult to grasp.
A number of years ago I took on a role to develop a physiotherapy exercise service integrated with local council services. However, when my assessment of the governance structure revealed significant holes it took a lot of unpicking to address them. This experience showed me how clinical governance is a true swiss cheese problem. Each element on its own may not lead to a significant misstep but if all the holes line up then every level of the organisation feels it from the patient and the clinician to the organisation and their partners.
More recently I have been involved in leading the implementation of the First Contact Practitioner/Physiotherapy (FCP) service and structure in Gloucestershire. FCP roles offer a glimpse into the potential of integrated services across primary, secondary and community care but equally they offer the possibility of a perfect storm from a clinical governance perspective. Each GP surgery, Primary Care Network, Clinical Commissioning Group, NHS Trust and clinician will have different priorities and experiences which could lead to a variety of implementation models across the country. Keeping patient safety and clinical effectiveness at the forefront of any implementation is therefore imperative.
I have scoured NHSE, NHSI, HEE and CSP documentation to find the holy grail of clinical governance. A standardised, universal, regulated support document providing guidance on implementing clinical governance structures for Advanced Practice, MSK or FCP services. I haven’t found it.
In the absence of this golden chalice I read the available literature and documents from the UK and travelled to parts of Australia and New Zealand through my Churchill Fellowship to discuss what clinical governance arrangements advanced practice services had implemented there. I have detailed my Fellowship findings and amalgamated the guidance available from the UK, Australia (specifically Victoria) and New Zealand.
This essay concludes by drawing together the available supporting information and making some recommendations specifically relevant to FCP and/or advanced practice MSK services taken from my reading of the literature, available documents and observations during my Churchill Fellowship.
The landmass of the state of Victoria in Australia is approximately equivalent to the land mass of the UK and the population is slightly less than the South West Region of England (4.7 million Victoria versus 6 million SW England). I was fortunate to spend time with the Australian Physiotherapy Associations (APA) Advanced Musculoskeletal Practitioner (AMP) Network. The networks members have been prolific in publishing details of education, patient outcomes, state-wide implementation and competency frameworks for advanced practice services.
Internationally, first contact physiotherapy is accessed in different ways depending on the structure of the health service. In Australia, GP visits are chargeable and this means many patients access immediate care through their Emergency Departments (ED), rather than through primary care. This has seen the growth of FCP in ED rather than GP surgeries. In a benchmarking of AMP roles in Victoria ED roles were the second most popular AMP service and had the largest proportion of senior (level 3a) roles.
Clinical risk management.
Governance arrangements in AMP roles in ED in Victoria included close relationships with medical teams. Imaging varied between independent or through predefined pathways for ordering xrays, ultrasound, CT scans, MRI and pathology. To support education for imaging some sites utilised online radiology education tools, one site required a formal assessment of radiology training and another required an external radiology course to be undertaken. During orientation into a new FCP ED role one site required initial image requests to be checked by the ED consultant. In one site an annual audit of 500 x-ray requests was required to be deemed independent. Although methods varied each site had a governance structure to provide quality assurance for image requesting.
Other advanced practice skills in FCP roles in ED included wound assessment and management, providing a single dose of analgesia (paracetamol or ibuprofen) and reduction of fractures and dislocations independently or under direct supervision from an ED consultant.
Induction plans for new starters in AMP roles also varied across sites. All sites had a local orientation process and some had an orientation checklist, introduction to competencies and review of clinical guidelines as part of their induction period. Induction included a selection of supervised shifts for 8-12 weeks. Supervision hours varied between 8 to 40 hours minimum across different site and was dependent on FCP experience level. Supervision took place either during or after patient contact with observations and/or discussion of the session and/or documentation. One site offered monthly personal development discussions and one site offered group supervision with medical colleagues. In the roll out of further ED sites lead sites were allocated an implementation site to mentor and support providing a buddy system.
Education and training
Education and training options also varied but were formalised in some sense across most sites. Formal competency documents were utilised in all but one ED FCP service in Victoria, 64% required clinicians to have completed or be working towards a Masters of MSK Physiotherapy and some sites required seven years of clinical experience to apply. Competency documents in some sites were consistent between FCPs and Medical Registrars. Levels of competency allowed practitioners being inducted or supervised to independently assess and manage patients who fitted an inclusion criteria for uncomplicated MSK conditions, cases not fitting this criteria were discussed with the medical team. This allowed the gradual exposure of new clinicians to more complex presentations.
Assessment of competence was different between sites but most included a formal assessment. Case based presentations were widely used and varied in frequency (from one or two annually, to 8 initially or on rotation) and structure. Presentations topics covered upper limb, lower limb, spinal, radiology, pathology and pharmacology. Clinical logs were required by the majority of sites and included procedures, radiology requests and fracture reductions.
Credentialing was offered to FCPs through the Allied Health Credentialing and Scope of Practice Committee. Recredentialing was required in some sites, either annually or every 2-3 years through audit, radiology quiz, portfolios or work based observations.
The documents, guidelines and frameworks available to support the implementation of a robust clinical governance programme in Victoria were numerous and comprehensive. There were some similarities with our practice in the UK but also some suggestions that could be made which I will draw attention to in the recommendations section.
Wellington, New Zealand
The population of New Zealand is less than 5 million at the time of writing, this compares to a population of over 9 million in London and 6 million in the SW England. The West Coast District Health Board of South Island New Zealand covers a patient population of 32,400 this compares to around 50,000 patients in the St Pauls PCN, a cluster of 5 GP practices in Cheltenham where I work as an FCP. I document these stats to demonstrate the possibility of comparisons between the New Zealand governance structures as a whole compared to a region of England or even single PCN.
In New Zealand, like Australia, GP visits are chargeable and so FCP services have developed in ED departments in a similar way. However, a particular nuance of the New Zealand’s health system, the Accident Compensation Corporation (ACC), has created a unique model in which FCP and advanced practice has developed in a different way.
After spending time with advanced practice services and specialist clinicians in New Zealand there are significant differences in the context and application of first contact and advanced practice in New Zealand compared to the UK and Australia due to the health system and regulation of roles. Therefore, in this conversation I will separate the definition of advanced practice and first contact physiotherapy from the conversation of clinical governance. Instead, I would like to use this space to study the governance support and guidance offered by the New Zealand Board of Physiotherapy (NZBP) for all physiotherapy practitioners and consider the application to FCP services in the UK.
The NZBP provide not only a framework for clinical governance but also a guide to developing a clinical governance framework specific to the organisation. In this guide they recommend identifying key stakeholders and communities who may be able to contribute, identifying existing structures and processes and understanding the organisations vision and values.
The guidance also suggests questioning the framework that is developed and offers a set of questions to reflect on. The approach of the NZBP guidance is one of curiosity and exploration. It encourages seeking out established procedures, sharing and reviewing in order to develop safe and effective processes.
I was once asked, in what I perceived as an aggressive manner, whether my service and practice was safe. I felt affronted which may partly be due to the culture and environment in which this question was posed. However, a culture of open exploration and safe collaborative review, as is proposed by the NZPB guidance, encourages this level of questioning as a way of supporting the adherence of practice to clinical guidance principles. This is something the NZBP guidance does well, it understands the effort required in developing positive culture.
The guidance talks about intent, meaning, value and alignment with expectations and principles. The guidance also draws out the importance of linking processes, providing connections and making joining up clinical governance activities in order to identify gaps to create a coherent, coordinated framework which complements existing processes. This approach seeks to embed vision, mission and value into the implementation process and offers a foundation of collaborative connections.
“Whānau are those to whom the person relates in terms of shared experiences, values and beliefs. The people and relationships that comprise a person’s whanau may be lifelong, or time-limited and specific to the person’s life circumstances. ”
An aspect of clinical governance modelling detailed in PTNZs guidance which is unique to New Zealand is Whanua. Whanua is a Maori word (see above) roughly meaning family, community and environment. The guidance impresses the need for an organisation-wide commitment to person and whanua engagement and participation in the development and implementation of clinical governance frameworks.
The NZBPs clinical governance guideline and domains have a principled tone, particularly in comparison to the Australian and UK documents. From their “Person, whanua and staff safety” domain they highlight the need for a “no-blame” approach in an environment of continuous learning focus. In their “Clinical effectiveness” and “Engaged and effective workforce” domain they set out processes needed for sharing learning and improvements and suggest staff partner in clinical governance initiatives to increase their awareness and participation.
They also discuss the importance of engaging with “person and whanau” in culturally appropriate ways by actively seeking opportunities to understand the views, needs and perspectives of others and use these insights to inform service delivery and evaluation. NZBP stresses the importance of developing meaningful relationships with patients, their whanau and staff in order to gather meaningful engagement at every level of governance. The language used is one of inviting discussion and understanding citizens’ experience of care and collaborating with citizens.
Mapping across the globe
Mapping these requirements onto the UK perspective we can look to Health Education England (HEE) and the Chartered Society of Physiotherapy (CSP) for some of these governance pieces. The CSP provides an implementation checklist, staff induction checklist, documentation audit template and Standard Operating Procedure xray investigation template. HEE provides an implementation guide, core competency document, multi-professional framework and an advanced clinical practice toolkit with e-learning modules on the e-lfh website. HEE’s MSK competency document is in agreement with the majority of Victoria’s FCP ED sites in requiring a level of Masters study and the British Medical Association (BMA) GP contract (Jan 2019) and guide for implementation co-authored by CSP, BMA and Royal College of GPs recommends FCP posts be graded at UK Band 7 or 8 which is equivalent to a Australian level 3a or 4.
There are several suggestions which could be implemented taking the best bits from this exploration of clinical governance arrangements in Victoria, New Zealand and UK Advanced Practice FCP services. I will outline some areas for development and learning here.
Visions and Values
Let’s begin at the start: taking a leaf from the NZPBs book and giving some headspace to understanding the vision and values of the organisation. Also being aware of your own values and those you would like to see reflected in the team and the service you work in. It also helps to understand the goals of the commissioner. If the commissioner is a PCN their goals for an FCP service may be different than if the commissioner is the secondary care organisation. By having clear values, differing goals can still be achieved in a way which aligns with the principles of good governance and best practice.
Citizen engagement: cultural competence
The principles and values shared in NZBPs guidelines demonstrate the importance of citizen (person, whanua and tangata whanua) engagement in their process. They also stress the need for meaningful engagement and collaboration. The AHP in Action document, produced by NHSE, discusses the involvement of AHPs in the health and wellbeing of the population, community, families and carers and the importance of using citizen outcomes to develop individual care. One way to build on this approach would be an acknowledgement of the cultural diversity of our citizens as demonstrated in the NZ documentation.
The NZPB also address the importance of wide citizen engagement and recognition more directly. In their professional development clinical governance table NZPB list cultural competence, diversity and inclusion, unconscious bias and mental health as mandatory training. Another suggestion made by NZPB is cultural supervision, also known as reverse mentoring.
Our guidance and frameworks should recognise the range of approaches which may be required to meaningfully engage with a more diverse range of citizens. We could follow this example by including these areas as part of mandatory training for all staff. This is something the NZ approach tries to address by discussing it openly in their frameworks and may allow a more open and realistic expression of our communities.
Credentialing is widely used in advanced practice in Australia. In NZ specialist physiotherapists are separately regulated and they are debating whether to create another regulatory level for advanced practitioners. A credentialing programme is not available in the UK at this time for advanced practitioners or FCPs however there is the possibility of an Advanced Clinical Practice Academy or Centre for Advanced Practice which could oversee this process in the future. Keep an eye out for the work led by Richard Collier for developments in this area.
Competencies, Supervision, Mentorship
I have not found any recommendation or evidence of FCP competencies or development plans being consistent between FCPs and GP Registrars and this could be worth some consideration. There is also a current lack of guidance for levels of supervision, mentorship and competency assessment methods within the UK literature although I understand there is a project with HEE underway to address this (look out for work led by Amanda Hensman-Crook here).
One document I found very helpful was a risk register shared by Paula Harding, Clinical Lead for AMP Services in The Alfred Hospital, Melbourne. A risk register attempts to foresee all the possible negative outcomes and risks an approach, service or role could have and allows these to be planned for in advanced. It is a great tool for developing clinical governance structures and assists in the development of escalation plans which can be put in place in response.
In conclusion, the development and implementation of a regional (if not national) framework for clinical governance of FCP services in primary care would be hugely beneficial. A very worthwhile read is the recently published HEE document offering a retrospective review of FCP MSK model which has a similar recommendations. This document emphasises the importance of clear governance discussions to ensure standardisation and quality assurance in an environment when the MSK workforce in primary care may comprise of different implementation models and employment structures.
From this exploration of governance documentation and framework I have complied a Combined Clinical Governance checklist which I would be happy to share, please message me directly for access.