Can you describe the supervision provided to you?
They had almost handholding process initially where we worked with doctor and she would bring you into the fold. What primary care looked like, you'd have that mentorship support, and I also had a physio in primary care at the time that was supporting me. Once I found my feet, I could do that on my own but then I've still got [supervising GP] to do my qualifications with me. I'm currently doing my prescribing course, and just finished my steroid injecting course.
What does a typical week look like?
A typical week is a like a normal GP practice clinic or an NP clinic. I have a combination of 20 minute appointments or some 30 minutes. This is a slightly different model than the traditional first contact physiotherapy model in primary care. The reason for that, is we’ve got a little bit more freedom to explore the nuances of what a Physio could provide in primary care. It's helped us provide a service where you become the first contact practitioner for a patient who presents with an MSK problem, which is great, and largely that's still what I do. But some patients may have more complex, chronic pain or persistent pain, years in the making.
It's through the Academy I was able to go and spend some time in different teams, one of which was the pain management team. I got to learn a little bit more about what they provide, what can I bring back from them into primary care that would help my own patients. We've recognised that complex chronic pain is quite a common presentation in in primary care, and unfortunately I'm not sure we've dealt with it perfectly in the past, because GP's traditionally don't have that long with an appointment. Pain management team have an hour appointment or more with these types of patients with multidisciplinary team members; OT, physios, doctors. What I've tried to bring in though is one a longer consultation time for these types of patients at the half an hour slot which is very helpful at times. The combination of working with the occupational therapist which we also have here, so like an MDT approach where I can refer on with them or we can have a joint appointment.
Other things I do, once or twice a week I'll do it a home visit, and that can be simple, such as this person could do with a walking aid, they're having problems with their mobility, that risk of falls. I can refer to community physio or social services but referrals can take a few weeks. If I've got the available equipment here, I can take a stick out to them on that day, assess them with it, measure it to them and that can be a safety intervention, either full stop or interim before they're assessed by the community team. It's a good way of bridging the gap and patients really do appreciate that.
What is special about your profession in primary care?
Because I've been on the Advanced Clinical Practice university course, I did a lot of work on additional things outside of my traditional role, such as respiratory assessments, cardiovascular assessments, neurological assessments. So one example, the patient came in with shoulder pain, in their 60s, still working, normally fit and healthy but was a smoker. I did a shoulder assessment which is what they were booked in for but it didn't seem to be the shoulder. Because of my training I was able to do a respiratory assessment of their chest, listen a bit more about their story, smoking history, the cough, the pain, because of that history referred for a chest X-Ray. Unfortunately it revealed quite advanced lung cancer but I'm glad that I had those extra skills in my kit that could do that multifactorial assessment, which was good. What the Academy has provided is a clinician that's a little bit more, well rounded, that can deal with some things outside of their area.
What does it mean to you to work in primary care
Primary care is exciting because, you don't what's going through the door. The booking can say knee pain and then within two minutes of that conversation you can realise it's not to do with their knee at all, but it's to do with their back, it can be nothing to do with their body at all. It could be the fact that the they've had a change in circumstances over the last two years where they have been in lockdown. They used to go to Bowling Club and walking classes, they've lost some social elements of a normal lifestyle. “We're not going to that club anymore. We're not interacting with that person anymore”. Why don't we focus a bit more on the social prescribing side of it? And actually, all they were really looking for was some encouragement, but maybe also permission that despite having a bit of pain, they're okay to get going again with some of the things they used to enjoy. Primary care is a little bit like that, it's getting to know people in your community. You do what you can in those twenty minutes, but if you can, you look at the bigger picture, not just the knee or the ankle or the shoulder.
And the other thing I like is, patients at the moment are waiting months for traditional physio at the Community Hospital. What they get with physiotherapy available in primary care is they can be seen within a week or two of that initial presentation. Someone goes running, has knee pain, I can probably see them within ten to twelve days which means that you can reassure them, explain exercises, they get that initial input to feel like they know what is going on, that makes a big difference. Early access is important with physio.
What are the 3 key skills essential to your role?
Enthusiasm - Patients don't always feel very enthusiastic about their own pain, so you've got to bring the enthusiasm.
Optimism - Often they don't feel they are getting better or they're feeling quite low about it. So you’ve got to bring a sense of optimism and hope that things can improve.
Listening - Be a good listener. Make sure the patient feels heard, because often that's the main thing the patient will complain about in health generally. Make them heard, validate their concerns and then nine times out of ten, be able to reassure that it's not as sinister as they feel it is. A sense of listening and communication and validation is a very important.
What has been your greatest area of learning from primary care?
I think doing small things well makes a big difference. One of them is listening. Secondly, you realise if they're only going to see you once for twenty minutes and not going to be booked in for review or another appointment, you need to show them what they can do. Reassure and provide the tools necessary to help themselves and create a sense of empowerment. Traditionally in physiotherapy, you book them in for review in three weeks, I haven't got that luxury here. So you have to do small things well, quickly, safety net if it gets worse or isn't getting better, give clear cut information.
What is the benefit of having a Clinical Specialist Physiotherapist for primary care/practice/patients ?
Being part of the Academy rather than being part of the physio initially, allowed me to embed myself more as part of the team. I will go to them with a question, they'll come to me with a question and we team up a little bit more. We run educational sessions on MSK stuff, they run educational sessions on prescribing and medications, it's a little bit more team ethos. So what I'd like to do is maybe run a monthly lunch time session on shoulder pain, hip pain, the basics, and that would improve the quality of care for patients.
I can't see it all the MSK problems in Prestatyn in the practice, there's too many, so they get seen by the GPs and the doctors and the nurses, which is great. It's just their confidence with those types of conditions isn't as good sometimes, which is understandable. I can give them some basics to build that confidence of the main things to look for.
What plans do you have to develop the role?
I've just passed my injection course, it's steroid injections, shoulders, knees, and hips. I'm doing the modules and the prescribing course which requires me to build portfolios and spend time with other clinicians.
When the modules finish and I've got the qualifications then we can focus a little bit more on the development, the service, I can see certain factors being important. One is the OT-Physio combination. There's only one of me, but I would like to setup a once weekly or once biweekly long term pain management group that runs for two hours that we could book cohort into. Let's say we have a maximum of eight people and make it more of a peer support group which would provide access in primary care to some of the interventions that are available in more depth in secondary care. We could start that off here and it would be a an eight week programme on education, coping strategies, goal setting, pacing management etc. All the things that benefit people with long term pain and we could give them a taste of it here before possibly then going on to the being referred to pain management, that would be a big one.
What advice would you give to somebody interested in becoming a Clinical Specialist Physiotherapist?
It's the most fun job I've had in physiotherapy because it's just very varied. You see lots of different types of things, but you also make a big difference. It's quick paced, but in actual fact I think more rewarding than traditional physiotherapy MSK jobs. Even though it's not that unusual anymore, patients are still surprised to get access to a physio within two weeks of that issue starting and so a little bit more appreciative at times. Therefore more rewarding for you in some ways, you made a big difference earlier. So yeah, go and do it!
