Digital Innovation in Advanced Practice

Featured

Introduction

Data and technology is one of the fastest growing industries in healthcare. In recent years we have seen the focus on digital healthcare increase with the development of NHS Digital and the focus on technology in the Long Term Plan. In physiotherapy we have seen the emergence of the first digital network group within the Chartered Society of Physiotherapy (CSP), the first app library and a new digital physio series hosted on the CSP website. Data is driving more and more healthcare decisions than ever before and in an increasingly automated way. The effective use of data to make clinical commissioning decisions is changing the way funding is allocated and how organisations are incentivised.

While on my Churchill Fellowship I spent time with advanced practice services who had implemented innovative ways of working and many of these innovative practices involved data, technology and digitalisation. In this article I will discuss some of the services and solutions I found interesting and more importantly that clinicians and patients found effective.

Brisbane, Queensland

Telehealth

Telehealth is a mode of delivering health care related services to patients using technology. It can be used to deliver rehabilitation assessment and treatment using video consultation software and can mitigate many of the traditional environmental barriers to patients accessing services (Cottrell et al. 2018).

Simon Whitehart is the Telehealth Coordinator for the Royal Brisbane and Womens Hospital (RBWH) in Brisbane, Queensland. They run a telehealth service for patients referred to the Spinal Physiotherapy Screening Clinic & Multidisciplinary Service (SPSC & MDS). The SPSC & MDS telehealth service mirrors their face to face services with physiotherapy, occupational therapy, psychology, dietetics and pharmacy clinicians working as a multidisciplinary team for both assessment and treatment services.

RBWH implemented this service in 2017 to achieve two main aims. Firstly, to improve access for patients to treatment services and secondly to reduce waiting times for rehabilitation. Around 60% of patients referred to the SPSC reside outside of a metropolitan area. Patients living away from a regional centre behave differently when making healthcare choices to those with more readily available services. They might wait until the problem becomes unbearable before seeking specialist opinion, they might not attend an appointment or they might decline physiotherapy management due to travel distances. One patient who attended while I was visiting had travelled for 9 hours, including a flight and an overnight stay in order to access the clinic. This can be a huge disincentive to accessing care.

Regional and local treatment services had long waiting lists and although large regional centres such as Brisbane were not struggling to staff their treatment departments there were staff shortages at treatment centres outside of the metropolitan areas. Referring more patients’ to the regional centres to avoid long waits locally risks increasing waiting times all round. Telehealth can be cost and time effective and so telehealth services were implemented to help with waiting times in these areas.

Simon reflects:

“if that patient has no access to follow up and they might live in the Queensland interior, 200km to their nearest hospital. Or their local hospital has a two year waiting list for chronic. You think, right, I’m going to have to refer you to telehealth. To improve access we refer to telehealth”.

Alongside the implementation of telehealth for their multi-disciplinary assessment and treatment services RBWH also established a research fellow position which has resulted in a proliferation of evidence around the implementation of telehealth. Through this research they found a lack of clinician acceptance, resistance to change and poor technological self-efficacy were barriers to implementation of technological solutions or services. Before using telehealth clinicians were often concerned about safety and privacy and how they would establish the clinician-patient rapport online.

To address these barriers the RBWH team implemented a telehealth induction programme which included individualised training in the use of the telehealth platform and 3-5 days of offline time allowing clinicians to become familiar with the software and gather patient resources for online use before clinicians went live with patients. Cottrell et al. (2018) found that clinicians’ knowledge and confidence in using the technology and in delivering assessments and treatments via telehealth increased after this induction period.

In RBWH they use a web based telerehab platform called NeoRehab. I observed a patient telehealth session with Steven who is the telehealth treatment physio at RWBH. We are sat in a small office with a computer and a webcam attached to the top of the monitor. After Steven and the patient had logged into the system we could see into the patients’ home and she explained how her neck exercises had been helping her pain. Steven asked the patient to demonstrate her exercises side on to the camera so we could see her neck retraction exercise. Steven could take pictures or videos of the patient doing her exercises and either play them back to her or annotate on the pictures for her to see. This enabled a further means of coaching the exercise using the web-based programme.

Through my discussions with clinicians at RBWH and from the research they have published in this area a number of benefits to utilising telehealth as a mode of service delivery have been identified. For example, initial concerns such as safety and privacy of using telehealth were displaced after induction and once clinicians had been using the software. Clinicians felt clinical outcomes were similar with telehealth and face to face interventions and telehealth physiotherapists felt patients engagement levels were often higher when using telehealth rather than face to face rehab.

This assumption was tested by Cottrell et al. (2016 and 2018) by looking at agreeableness between telehealth and face to face outcomes and decisions in both treatment and assessment. They found that telehealth services improved physical function and pain outcomes. For physical function, telehealth in addition to face to face was more favourable than face to face alone. Telehealth alone was equivalent to face to face for improvements in physical function. Outcomes for pain were comparable between face to face and telehealth modes of delivery.

For services such as SPSC & MDS and orthopaedic assessment services they looked at agreement on a number of measures between face to face and telehealth assessments. They found substantial agreement (83%) for decisions regarding management pathways and diagnosis, moderate agreements (81%) for decisions regarding referral for further investigations and near perfect agreement for onward referral to other Allied Health Professionals. This suggests telehealth is a reasonable consideration for both treatment and assessment services in the future.

Overall there was a high level of satisfaction from clinicians who felt telehealth was cost and time effective and accepted that telerehab would be of clinical benefit to the majority of patients.

Education

Education of advanced practice physiotherapists is another area in which I found innovative practice being developed digitally. In Queensland they have developed a statewide education programme which has been covered in detail elsewhere in this report however here I would like to discuss the educational programmes digital capabilities.

Participants applying for the Extension Programme (the statewide education programme for SPSC & MDS teams) must ensure their work space is enabled with video conferencing equipment and software. The educational coordinator, Patrick Swete-Kelly, has learnt that using a laptop or substandard equipment is not sustainable for a 12 month distance learning course. The quality of the equipment and the users familiarity with it allows participants to engage in clinical debate, presentations to their peers and even observed assessments with patients while their peers give real-time feedback.

I was able to experience this digitally enabled medium several times during my visit through talks and presentations which were routinely broadcast to other hospitals and departments with colleagues logging in from several venues at once to watch the slides, see the presenter, engage with their colleagues and ask questions.

Utilising digital technology to run established education programmes such as the Extension programme and to share more informal presentations and gatherings like those I was involved with enables an equitable educational offering across organisations regardless of distance from the main hub. This approach is also time and cost effective allowing more clinicians to be involved from a more diverse area. Although there may be an initial outlay to ensure each site has the most useful equipment it can be used in many ways and is certainly beneficial for both educators and learners.

Christchurch, New Zealand

While in Christchurch I spent time with a number of services involved in innovative projects including community integration services, Canterbury Clinical Network and the Design Lab. These projects have been discussed in more detail elsewhere in this report but here I would like to highlight some of the digital and technological solutions they have implemented.

Integrated Community Services

The Integrated Community Service is led by Mardi Postill who shared with me her teams’ unique approach to identifying complexity within their community. In the aftermath of the Christchurch earthquake in 2011 Ms Postills’ team were involved with approximately 6000 clients who were in immediate danger. Despite this risk the team knew they couldn’t access all their clients at once. They needed to prioritise but they didn’t know who to go to first.

In response Ms Postills’ team has since created a complexity mapping system. This system allows teams to immediately assess the most in need by area code enabling individualised levels of risk to be assessed and care to be modified specifically for each client. This was achieved by analysing data the team already held due to national standardised data collection requirements combined with data sets which provided additional prioritisation knowledge such as medication, living situation and area code.

They used a nationally standardised frailty index called the interRAI as a key metric of patients’ complexity. The data provided by interRAI incorporates physical, mental, cognitive, clinical and psycho-social elements of frailty and provides a more holistic view of the patients’ complexity. The team overlaid the complexity assessment onto a map of the city. This allowed teams to identify which patients were most at need due to their frailty and which patients were most at need due to their proximity to any potential disaster.

The team now felt more prepared for any further disasters. Ms Postill suggested:

“if we get a notification a tsunami is coming and we know which area it’s going to affect we can quickly pin point who we need to evacuate”

This demonstrates the immediate benefit of the interRAI system in a disaster response scenario but they have also found this to be effective in long term strategic views.

“On a planning level we can see the complexity of the client, we can be strategic about where the population is that needs us.” Mardi Postill.

This unique approach to prioritisation in a disaster response has been maintained as a key metric in the years post disaster and has improved care quality from providers and changed the conversation around funding. Ms Postill considers how using data has allowed them to see the bigger picture:

“It (the data) has been a significant driver in us being able to see the system.” Mardi Postill.

The Integrated Community Team use provider organisations to provide care directly to their clients. Maintaining the use of the interRAI data sets has fuelled competition between providers which has driven up quality standards. Each provider submits basic data such as hours per client. This is compared on a dashboard to improvements in the interRAI assessment. If a provider introduces a new initiative which improves the interRAI for the same provider expense the open nature of interactions between the team and their providers encourages other providers to improve their offering equally. This approach drives an improvement in care quality for the clients.

Using data as their key metric has also changed the way they communicate with their providers about funding. They are able to use the data and the competition it creates between providers to analyse disparity between providers. Ms Postill reflects the ease of bringing providers to account when the team have objective data sets which demonstrate any outliers and help to bring care and costs into agreement.

Data Analysists

Dr Greg Hamilton is Team Lead for Planning and Funding, Transformation and Business Intelligence in Canterbury District Health Board. His team is involved in system-wide planning and funding for community services across commissioning, funding and service providers. They see themselves as future-focused system problem solvers. Their goal, as Dr Hamilton describes it, is “to allow citizens to fulfil their grand plan of keeping them at home as long as possible”.

The team includes an analytics team who are concerned with how data is collected and used from the provider networks. Data analysts work with clinical teams to test hypotheses. Dr Hamilton suggests that the best analyst is in the room with the clinician co-discovering the outcome and building trust between the data teams and the clinicians. This approach also assists with the transformation process because clinicians can find change difficult. Often feeling that change has been imposed rather than discussed and solutions discovered together. However, using this workshop style approach brings clinicians on board from the beginning.

The transformation team also provide clinical teams with a project management resource. Using a project manager directly involved with a clinical team drives projects forward by allowing someone from a portfolio background to step into the team, do some of the ground work and keep the project moving even if clinical needs increase. The project manager can process and manage the data which helps the transformation work go faster and clinical teams feel supported.

Dr Hamilton expresses his ambitions to be a truly data driven system. This is evident when heading into their headquarters where you are greeted by a wall of monitors showing the live admissions and discharges from any of the facilities in Christchurch. This database allows teams to predict bed blocking and plan for suspected increases in admissions. It also allows them to analyse the impact of small scale changes such as an additional role in ED, to large scale changes such as the expansion of their Acute Demand Management Service.

Recommendations

A specific and individualised induction programme is recommended for the implementation of telehealth services. This should include time for clinicians to familiarise themselves with the technology offline prior to use with patients. In recent times we have seen the dramatic shift of face to face consultations to online mediums such as AccuRx and Attend Anywhere in response to the Covid-19 pandemic. My observations and reading suggests that for telehealth to remain sustainable the choice of technology is importance and may be different for different professions or purposes. There is also a need to support ongoing skill development and provide technical support to ensure these changes remain a positive part of our service choices in the future.

Digitalised education programmes allow for more equitable educational opportunities and should be encouraged in all organisations. They can also be more time effective allowing clinicians to finish clinic lists prior to attending rather than having to cut patient lists short to travel to other sites. Investing in the most appropriate equipment is highly recommended as this is a key enabler to the success and sustainability of utilising technology in education.

Combining datasets already collected and using these to prioritise immediate care and strategise for future need has been successful in the Christchurch model and may be effective if applied in other contexts. It is important to develop the clinical question prior to engaging with the data rather than collecting or analysing without a clear purpose. This process should be linked to key strategic priorities in the organisation and the national direction of travel.

A clear ambition towards a data driven system and data driven innovation is admirable and the approach in Christchurch has been to encourage their transformation teams to reach out to the frontline, to provide support for clinicians, to collaborate with them on their projects and to graft alongside. This is not an innovative use of data or technology but an innovative use of resource and skill mix to reach data and technology goals.

Conclusion

Data and technology impacts all areas of healthcare. The innovative projects I have observed spanned the fields of education, integrated services, transformation and analytics, strategic planning and patient consultations. Collaborating with the available data, planning data collection aligned to organisational priorities and scanning the horizon for possible technological solutions are constant and evolving goals for any individual, team or organisation.

References

https://onlinelibrary.wiley.com/doi/abs/10.1002/gps.5171

Hospital avoidance: an integrated community system to reduce acute hospital demand

https://www.researchgate.net/publication/336877712_Hospital_avoidance_an_integrated_community_system_to_reduce_acute_hospital_demand

The impact of the Canterbury earthquakes on dispensing for older person’s mental health

https://www.researchgate.net/publication/334384424_The_impact_of_the_Canterbury_earthquakes_on_dispensing_for_older_person’s_mental_health

Impact of integrated health system changes, accelerated due to an earthquake, on emergency department attendances and acute admissions: A Bayesian change-point analysis

 

https://www.researchgate.net/publication/302984289_Impact_of_integrated_health_system_changes_accelerated_due_to_an_earthquake_on_emergency_department_attendances_and_acute_admissions_A_Bayesian_change-point_analysis

Analysis of educational programmes for Advanced Practice Physiotherapists: Queensland, Victoria and Christchurch examples.

Introduction

I have been aware of the scaling up of the advanced practice agenda in the UK has for a number of years with work of Health Education England (HEE) and the Chartered Society of Physiotherapy (CSP) continuing to provide fantastic leadership in this area.

I was first aware of advanced practice in the clinical setting during my first junior rotational position. I was based at St Woolos Hospital in Newport outpatient physiotherapy department. To the right side was the treatment room with standard plinths surrounded by polo-shirt clad physios chattering away to their patients behind wispy curtains. To the left was the physio gym, but only the bravest polo-shirt wearing physios frequented this area as it was the territory of the shirt and tie wearing MPT3 team. At this embryonic point in my career I knew I wanted to be in that room but had no idea how to get there.

Thankfully, I made my way there with the help of some great mentors to point the way but there was certainty no career framework, structured mentorship or education programme to follow. When planning or developing educational frameworks for advanced practice we should remember this mesmerised new grad looking to the years ahead.

How do we develop a programme of education which is meaningful to the participant and their current and future employers? How do we develop a programme which stretches the limits of education and advanced practice? Participants and educators dedicate incredible time and energy into these programmes and so we have a responsibility to ensure that effort is transferable and widely recognised across organisations and geographies.

In this article I will explore the range of educational programmes I came across during my Fellowship and compare these approaches. I will make several recommendations which could be considered when developing or improving the advanced practice educational programme within our organisations.

Queensland, Australia

Patrick Swete-Kelly is the Educational Coordinator for the state-wide Extension Programme. A comprehensive educational programme for aspiring advanced practice physiotherapists. The programme has high standards with participants requiring nomination by their clinical lead and mentor.

Committing to the programme

There is a single intake per year and competition is high, as is the participant commitment. Participants and their managers commit 0.1 FTE to the programme every week for 12 months and the participants themselves are advised to limit their annual leave during this period and to be prepared for 3-6 hours study outside of work and the programme hours per week. Participants do not typically hold an advanced practice position when they embark on the programme but their managers are required to give them increasing experience of the role and service during their programme. They are also not guaranteed an advanced practice position when graduating from the programme but in a follow-up of programme graduates all clinicians who sought a position in the 12months after their programme were successful.

State-wide roll out

The programme is designed specifically to address potential future workforce problems in the Neurosurgical and Orthopaedic Physiotherapy Screening Clinics (N/OPSC) throughout Queensland. During the state-wide roll out of the N/OPSC the team conducted a workforce analysis which demonstrated that many facilities did not have sufficient capacity to provide backfill for planned or emergent situations or to meet future expansion plans. This was the motivation for developing the Extension Programme which is a centrally co-ordinated and delivered program, supplemented with local support and supervision. The programme also tackles another difficulty many employers face; the retention of skilled staff and sustainability of the recruitment pool.

Using Technology to Bridge the Distance

The Extension Programme is unique and innovative in a number of ways. It is a state-wide educational programme from Cairns in the North to Brisbane in the South. Queensland is seven times the scale of the UK so this endeavour is truly impressive and requires some ingenious developments including extensive use of video-conferencing and telehealth.

Participants sit alone or with their local colleagues in a room with a fully equipped video-conferencing suite which is a requirement of sites wishing to admit clinicians onto the course. They receive the majority of their educational instruction and engage in clinical debate through video conferencing. Participants are also required to attend 3 face to face education sessions, 2 days each and attend a one day annual forum during the 12 month programme.

Observed assessments are an important part of the programme but the distance between sites is clearly a barrier to this. This is overcome by using video-conferencing integrated into clinical observations. Participants and the educational coordinator draw around their screens as the participant being observed carries out their patient assessment. Patients are aware of the benefit which their participation has for the development of the workforce and it offers the opportunity for observing colleagues to pause the assessment at any time to ask questions of the clinician and to reflect in action.

The design and contents

The curriculum for the programme aligns with the Physiotherapy Career Pathway Competence Framework from the Australian Physiotherapy Association (APA) and International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) standards. The programme delivery is based on adult learning principle of doing rather than watching, immediate relevance, active involvement, clear goals and objectives, constructive feedback, opportunities for reflection. The programme can be flexed to suit the needs of the participant using tools such as a Learning Needs Analysis.

The programme provides consistency across a large area, reduces duplication of time and effort by clinicians and their teams and promotes equity of educational provision for all MSK clinicians across the state. The programmes structured requirements of both the learner and their team ensures a robust approach to governance, mentorship and continued professional development. The small group size and length of the programme encourages peer support and means the programme can be adapted to meet the needs of the learner and the group.

Victoria, Australia

In 2015 a team led by Paula Harding were funded by the Department of Health and Human Services and Health Workforce Australia to develop the Advanced Musculoskeletal Physiotherapy (AMP) Clinical Education Framework (CEF). The team approached this task in a methodological way and published their results in the Australian Health Review Journal.

A step-based approach

They used a step-based approach by conducting literature searches and focus groups. In the focus groups they discussed the key attributes needed as an AMP and the education and training required for AMP roles. The analysis of the scoping review and the focus group led to the teams’ decision to develop a competency based training and assessment approach in a workplace setting.

The Clinical Education Framework assumes that clinicians meet the pre-requisite of the Australian Standards for Physiotherapy and builds additional knowledge, skills and behaviours for AMPs on top of this. The key components of the CEF include competency standards, a learning needs analysis, learning and assessment plan, self-directed learning modules and a competency assessment. The competency standards were developed by an experienced team of subject matter experts.

Implementation and evaluation

Once the CEF was developed it was implemented in a small number of test sites and its use and feedback closely monitored and a formal evaluation carried out. Once the CEF had been developed a follow-up focus group with AMPs was conducted for further feedback and verification. The CEF was then adopted across Victoria as a formal assessment component and is used to credential AMPs. It allows prior learning and clinical expertise to be recognised and supports the transferability of staff between organisations.

The CEF consists of a manual which is applicable to a number of AMP roles and services including Rheumatology Screening Clinic, Neuro-Surgery Clinic and Post-op Clinic, Paediatric Orthopaedic Screening Clinic, Joint Arthroplasty Review Clinic, ED Soft Tissue Review Clinic, Primary Contact ED Service, Pain Services and the Osteoarthritis Hip and Knee Service. The attributes identifies from the focus group are summarised into operational, interpersonal skills, attitude and communication, experience and clinical expertise. The pathway was also split into a continuum from pre-entry, supervision, independent to clinical lead. This model provides a simple over-arching structure to the CEF.

Evaluation of the CEF found that clinicians struggled to fully understand the structure initially. During our conversations Paula Harding reflected that some clinicians struggled to identify their specific learning needs and instead could be overwhelmed by the sheer volume of material and options hence the importance of a strong mentorship and supervision element to the programme.

Christchurch, New Zealand

In Christchurch I met with Vince Barry, CEO of Pegasus Health. Pegasus is a charitable organisation which supports general practice and community based health providers in Canterbury. They run an Educational Rounds series to support educational development for their general practice staff. This is not specifically for advanced practice physiotherapists but as it is a different model which may have application to advanced practice and specifically FCP services in the UK I felt it important to share here.

The Educational Rounds have been such a success they have expanded out of Canterbury and there are now groups in different areas of New Zealand using this methodology. An Educational Round consists of a group of clinicians from different GP practices. They are split into teams and the teams are mixed with clinicians from different practices, different interests and different levels of experience. Clinicians stick with the same team throughout the different rounds. The group decides on a number of “Wicked Issues” which they come across in their practice which they would like to focus on. Wicked Issues have included topics such as, supporting people from and managing illness in the transgender community, talking to men about mental health and coaching for lifestyle choices. These topics are not the most common problems clinicians will come across in their practice but they require deeper discussions and the creation of a safe space within a diverse group of clinicians has been a very productive way to move conversations around these wicked issues forward.

The specifics of how the educational rounds function is also unique. They take place before or after clinic, sometimes 730am sometimes 730pm. All attendees are paid are small amount for their attendance, this amount has not changed in the years that the rounds have been running but Mr Barry feels this has helped attendance even as a token gesture. There is an educations team which supports the organisation and administration for the rounds. This team also provides the research and reading material which is sent in a pack prior to the event. This pack contains brief summaries and longer reading extracts or articles. The pack also proposes questions which should be worked through during the round. A facilitator supports the discussion and debate at the event. Events can be an hour to a few hours depending on the aim of the session and the topic.

Educational rounds and how they address wicked issues using debate, discussion and adult learning principles is unique and an approach which could be of benefit to many aspects of advanced practice education.

Specialisation

In New Zealand and Australia a separate specialisation level has been implemented. I have not approached this topic in line with my discussion about advanced practice education because in the New Zealand and Australian context “specialisation” and advanced practice are not comparable.

In Australia, Specialist is a protected title and the title is accompanied by a 2 year course taught by the Physiotherapy College. I spoke to a number of physiotherapists who had been through the costly course and did not feel it offered them anything over and above their previous title in terms of the roles they could pursue and opportunities available to them. I am sure there are many physiotherapists who hold an opposing view and certainly the breadth and depth of teaching on the specialisation course is excellent but the views that were expressed to me offers the opportunity to debate value and meaningfulness when considering educational developments.

In New Zealand, Specialist is a regulated level of practice which is assessed through a competency based portfolio and a panel interview. This is a very specific title and there are only 9 specialists in New Zealand (at time of writing), all practicing within a derivative of private MSK practice. I spoke to a number of specialists who defined the role as a referral only service in the majority with increased elements of assessment compared to rehabilitation and an increased emphasis on complex patients. Complexity was represented by chronicity of the MSK condition and failed treatments. I would offer that complexity in advanced practice roles in the UK, such as orthopaedic triage and first contact practitioner (FCP) roles, are also defined by high co-morbidity, mental health concerns, social difficulties and first contact assessments. This difference in complexity and the roles of advanced practice or specialist practice may be due to the differences between the structure of our health systems and how patients access care.  Of interest several public health leaders (District Health Boards) offered lack of value and meaningfulness to the specialist title within public health provision as a reason why specialists in New Zealand are largely in private organisations. New Zealand is now looking at regulating Advanced Practice as a separate regulated title as, as well as Specialist, this was being discussed by the Physiotherapist Board of New Zealand when I visited and it will be interesting to see how this conversation evolves.

From a UK perspective the developments in credentialing and regulating different levels of advanced practice in physiotherapy in other countries should lead us to question the benefits of pursuing this line of development. Particularly in terms of meaning and understanding for patients and in terms of value and cost for organisations and clinicians.

Mapping

In the UK we can consistently look to the leadership and support of HEE for guidance around educational requirements for advanced practitioners. HEE has provided us with the MSK core capabilities framework for FCPs and the Multi-professional professional framework for advanced clinical practice in England. These documents provide a framework for local educational developments to align around.

The Queensland Extension Programme provides a centralised coordinated educational programme. They were able to navigate the great distances between staff and services using teleconferencing. This is a fantastic way to coordinate educational programmes and their innovative solutions to peer learning and observational assessments provide an opportunity for UK based programmes.

In the UK there is innovative work being tried and tested around online education. For example, Project ECHO is an online community of practice offering tailored education and case-based learning for participating teams. Another example is TherapyLive, this is a virtual online summit offered by the Physio Matters team streaming debate and conversation around MSK practice free for all registrants. I have also had the great opportunity to complete my Masters in Pain Management with Cardiff University which was offered as an online MSc programme with all cohort discussion and debate through discussion boards and an app and all lectures uploaded onto a portal. These examples show that although virtual education is not the standard offering there are many examples of this work being embraced across the profession.

In both Queensland and Victoria education for advanced practice physiotherapists is focused on the skills and knowledge required by physiotherapists in advanced practice roles and even more specifically in musculoskeletal advanced practice roles. In the UK we do have the MSK Core Competencies for FCP Framework which is specifically designed for FCPs. However, all other work which I have come across seems purposefully generalisable to other advanced practice professions. Perhaps this approach is ahead of the curve in broadening skillsets across professions however it seems pertinent to highlight this as a specific difference between the countries in educational programmes and opportunities for advanced practice physiotherapists.

Recommendations

Frameworks and guidelines

In Queensland they conducted a workforce analysis and found that they would soon be struggling with their workforce numbers. This was the motivation for the development of their Extension Programme. Thanks to the CSPs workforce calculator we are well aware of the possible workforce requirements for FCP if every Primary Care Network (PCN) opts to use the Additional Roles Reimbursement Scheme to implement FCP services and yet we have not used this information to map to the current staffing available for these positions and those ready and waiting to fill them in the years to come. We have the MSK Core Competencies for FCP document but we have not followed this calculator and competency framework to its natural end point in establishing a national curriculum or educational guideline to support the implementation of FCP roles. This is an activity which could be led nationally, regionally or even locally through NHS Trusts, CCGs or groups of PCNs.

Career Pathways

The Victoria model provides a clear pathway from pre-entry to clinical lead advanced practitioner and the Queensland programme supports clinicians prior to achieving a position in their advanced practice teams. I have am not aware of a currently published document for advanced practice physiotherapy which provides this clarity of progression, although I am aware of work being conducted by the advanced practice and consultant practice groups in this area and look forward to their work.

Educational Coordinators

Coordination of educational opportunities outside of Higher Educational Institutes (HEI) is difficult for many reasons including large geographical areas, multiple service providers within the NHS and across the public and private sector and staff retention. However, in Queensland they have overcome some of these barriers and one factor in their success may be the allocation of a specific Education Coordinator role which is funded by the organisation for 0.4FTE in recognition of the benefits to staff experience and retention. This is an approach which I have not come across used in UK advanced practice teams. We are used to a senior member of the team being responsible for collaborative efforts towards continued professional development for the team but what about the CPD of advanced practitioners across a locality or region? Could this be a role supported by commissioners to develop advanced practice services across their jurisdiction or by training hubs to develop and retain staff within a group of PCNs?

Credentialing

The CEF in Victoria is used a credentialing framework. Once a clinician completes their CEF they are credentialed as an Advanced Musculoskeletal Practitioner and these credentials and this title is transferable across organisations which use the AMP CEF. At present we do not have a credentialing process nationally or regionally in the UK. This means that if an organisation works with its partners and clinicians to develop a Clinical Educational Framework or Programme it is not transferable to other roles or organisations. This makes it less desirable for staff as they may find themselves having to complete several service specific educational processes.

This is a barrier which could be replicated in the UK if we are not fully aware of the potential consequences. In England we are fortunate to have a centralised organisation for educational governance in health, HEE. The path towards advanced practice recognition which HEE seem to be exploring is closely linked with universities. This is not a path which was taken by AMP services and organisations which I studied during my Fellowship. Instead they adopted a centrally co-ordinated and delivered programme in Queensland and a competency based training and assessment approach in Victoria. The lack of similar programmes of HEI supported advanced practice programmes in my Fellowship studies leaves me wondering whether there could be an difficulty with transferability and grandfathering in this method.

Conclusion

Education of advanced practice clinicians could be a burden for many organisations but with some detailed thinking around structures and processes, with some supporting guidelines and frameworks and with robust evaluation advanced practice education is also a fantastic opportunity.

I hope my analysis of some of the educational programmes and approaches observed in other health systems can support some of the thinking and planning around advanced practice development, the increasing need for FCP workforce and the ongoing improvement of our clinical and strategic offering to the wider health system.

I have combined the educational curriculums from the service areas I visited. This combined curriculum offers principles, methods of delivery and assessment and curriculum content for advanced practices education. I would be happy to share this combined curriculum so please email me or reach out on social media if you would like access to this combined curriculum document.

References

https://www.qld.gov.au/about/about-queensland/statistics-facts/facts

https://www.hee.nhs.uk/our-work/advanced-clinical-practice/multi-professional-framework

Advanced musculoskeletal physiotherapy clinical education framework supporting an emerging new workforce, Harding et al. 2015

Advanced musculoskeletal physiotherapy clinical education framework supporting an emerging new workforce. Harding et al. 2015

Physiotherapists’ perceptions of workplace competency: A mixed-methods observational study.

A governance structure to aspire UK Advanced Practice and First Contact Practitioner Services: learning from each other

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.

 

Victoria, Australia

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.

Planning

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.

 

Principles

“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.

 

Recommendations

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

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).

Risk register

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.

Conclusion

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.

References

https://www.onlymelbourne.com.au/size-and-population-comparison

http://docs2.health.vic.gov.au/docs/doc/9713E9D3E616DE94CA257902000DD34C/$FILE/clin_gov_pol_framework-guide.pdf

https://www.england.nhs.uk/integratedcare/stps/view-stps/

https://www.csp.org.uk/system/files/001404_fcp_guidance_england_2018.pdf

https://www.hee.nhs.uk/sites/default/files/documents/FCP%20How%20to%20Guide%20v21%20040919%20-%202.pdf

https://www.appn.org.uk/cms/wp-content/uploads/2015/08/ALP-in-physiotherapy-final.pdf

http://arma.uk.net/wp-content/uploads/2020/04/MSK-march-2020-v2.pdf?utm_content=buffer043a7&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

https://www.appn.org.uk/research/publications

https://www.appn.org.uk/cms/wp-content/uploads/2020/04/CSP-briefing-statement-on-advanced-level-practice-Final-1.pdf

https://www.csp.org.uk/professional-clinical/improvement-innovation/first-contact-physiotherapy-2/implementation-tools

https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf

https://www.nhsemployers.org/news/2019/04/consultation-on-the-academy-for-advancing-practice

https://www.england.nhs.uk/wp-content/uploads/2017/01/ahp-action-transform-hlth.pdf