Dr. Rob Goodwin - SUPRA CPD Takeover

The first installment of the SUPRA CPD Takeover sees hosts SUPRA President Jack Ledger and Vice-President Josh Griffiths discuss the development and future of the First Contact Practitioner role with one of the main stakeholders Dr Rob Goodwin, while also delving into how interested students may go about pursuing an FCP role during their future careers! Tips, tricks and fantastic insight, listen in!

Transcript

UNKNOWN: 0:00

so

SPEAKER_04: 0:10

Hello and welcome to the It's Not Just Physio podcast. This is the first episode in the Supra CPD takeover. Supra is the University of Nottingham's physiotherapy and sport rehabilitation society and I am Jack, the president of Supra and I'm joined with Josh to my left who is the vice president. Hello everybody. Today we've got a very special guest, we've got Dr Rob Goodwin with us who was one of the main stakeholders in the development of the first contact practitioner or physiotherapist roles. So, hello Rob, how are you feeling about being on the podcast today?

SPEAKER_00: 0:47

Well, first of all, hi, and thanks for asking me. I listened to some of the previous podcasts and I think I heard Fiona say that she was quite nervous and it's, you know, I was coming in this morning and I thought, well, that's, you know, I don't think I will be, but sitting here now, definitely there's a degree of anxiety. So, I'm really pleased that you've asked me to come and I hope it goes okay and I hope what I've got to say is useful for you guys as students and perhaps wider than that as well.

SPEAKER_04: 1:15

So, yeah, we're just going to ask you to introduce yourself, well, you already have, but your background and then we're just going to get you to obviously think about kind of more the student focus or any tips and go into that FCP role just with us being the student society and it'll go towards our members. So, yeah, why don't you start with a little bit about yourself, a little bit about your background and how you got to where you are today. Yeah, okay.

SPEAKER_00: 1:40

Well, so I'm obviously a physiotherapist. I qualified in 1990, which feels like a long time ago now. And I'm probably, if you do a number of these podcasts, I'm probably the least exciting physiotherapist in terms of geographical sort of experience and exposure. So I did my training in Nottingham way back when it was a graduate diploma of physiotherapy. And then I got my first rotational post at this hospital, Queen's Medical Centre. So I did my basic rotations here and then I specialised in orthopaedics. So I did my senior two rotations, as they were called then, through A&E, fracture clinic, orthopaedic clinic, on the acute wards and on the elective wards and on spinal disorders unit. So I got a really broad experience there. And then I sort of dabbled in, I suppose, biomechanics. So I got a job with a private company who were doing biomechanical assessments for professional athletes and that was my shortest ever job I was employed for about a week and then the American company who had provided the funding for the British experiment I suppose pulled the money out so literally I was in that job for a week so I came back to Queens and did a short stint here and then I went to a rehab centre again in Nottingham which was called Cedars which was probably the sort of centre now that physiotherapy is crying out for but has generally been shut so it had a hydrotherapy pool it had a workshops manned by OTs had a big gym an apparatus gym and patients were there for half a day or a full day three times sometimes every day of the week so fantastic facility and there are very few if any of those sorts of facilities in the NHS that are left and then when I was there I started to specialise in pain management so myself and a colleague set up probably the first pain management programme in Nottingham and that really sparked my interest in the BPS approach and so I'm a real strong advocate of that and I worked for a team called the Nottingham Back and Pain Team which provided pain management programmes for people with long term pain and back pain and alongside this all the time I've been interested in sort of evidence based practice so undertaking audits and things like that I had a private practice locally in Nottingham again and then got the opportunity to start to dip my foot further into the research world and all of my research has been around the sort of FCP first contact practitioner post if we call it FCP it makes it a bit easier and I did my PhD in that started in 2015 and finished that in 2019 went back to a clinical academic post and which was just the time that covid hit so really didn't do much academic work then and then my academic world has reopened again in april of this year so i started a two-year post-doctoral fellowship that's funded by the school of primary care research which is again looking at elements of the fcp post

SPEAKER_03: 5:01

brilliant perfect so lots of experience and and different challenges throughout your career uh if we can focus on sort of the fcp role today and just go into a bit of how that developed and the idea you had and how you got started with that

SPEAKER_00: 5:14

yeah absolutely yeah so I think there were probably two things that really motivated me to start to think about FCP and I suppose a disclaimer right at the beginning is anything I say about FCP really is my own opinions so they're not necessarily reflective of anybody who I work for or the CSP and I'm sure that there will be people who have very different opinions to mine But in the early 2010s, there was a couple of things that coincided that really got me enthused to start to think about putting physiotherapists closer to the front of the patient journey. And those two things were self-referral physiotherapy and the very, very strong narrative that I felt I was hearing in the media coming from general practice that was led by GPs themselves so self-referral physiotherapy and a big shout out to Leslie Holdsworth who did the sort of pioneering work around self-referral physiotherapy up in Scotland and that was hugely influential to what I was interested in so I work clinically and I'm still employed clinically by an organisation called Nottingham City Care which provides NHS services within Nottingham City so they're a social enterprise And we had had, when I joined the team, they had already got self-referral physiotherapy and they'd had it for several years. So by the time I joined, they must have had self-referral physiotherapy for at least five years. And as a service, they received upwards of 1,200, 1,500 referrals every month into their community MSK service. So it was a really big, a really busy MSK physiotherapy service. And on the face of it, it was a self-referral physiotherapy service. physiotherapy service. But when you spoke to almost every patient at assessment, they'd all come to you via their GP, or almost all come to you via their GP. So to me, it was just clearly obvious that self-referral wasn't working in the way that it was designed to work. It's a little bit like it does what it says on the tin. Self-referral is patients, through their own volition, make the decision to refer to physiotherapy. And these patients weren't doing. They were seeing the GP And the GP was referring them to physiotherapy. of GPs and lots of GPs were deciding that they wanted to work part-time. So there were lots of stories almost every week, every fortnight of, you know, this is unsustainable, GPs are overburdened, overworked. So I just thought, well, these two things surely go together in a very commonsensical way. If the proportion of patients that saw a GP with an MSK problem actually utilised, through their own choices, physiotherapy as an alternative, then surely surely that would, one, make self-referral work in the way that it was meant to, and two, it would take some of the burden away from GPs. And the statistics at that time, and the often quoted statistic, is that 30% of a GP's workload is MSK-related problems. So I thought, that just makes common sense to try out seeing if you can divert that group of patients. So I went to our local commissioner and I said, why don't we trial a one year evaluation of putting physiotherapists into GP practices and getting them to see a proportion of the patients with MSK problems as an alternative to the GP and thankfully they agreed to do that and they funded two physiotherapists and this was really really small scale so the two physiotherapists both worked two half days in two GP practices one of those was a university practice And one of them was an inner city practice. And as part of the pilot, we were absolutely committed to gathering as much evidence as we could in a very sort of pragmatic service evaluation. And then myself and Paul Hendrick, who obviously teaches you guys, we wrote that up and thankfully got that published. And that was the first sort of peer-reviewed publication around FCP that there was. And it showed that patients generally got better when they saw the physios. The patients generally were satisfied with the service that they received from the physios. There were no adverse events recorded and we did a very, very back of a fag packet evaluation of cost and it seemed to show a reduction in costs compared to a retrospective cohort of GP patients that we sort of went back and had a look at their sort of resource utilisation so how many MRI scans, x-rays, how many referrals through to secondary care and the physiotherapy service seemed to show cost effectiveness and benefits compared to GP practice. So that was really the beginning of FCP for me and it was born out of those two motivations really. I don't think that I can take claim to be the father of FCP godfather of FCP I'm sure there were other people around the country who were doing similar things at that time there were there were things called vanguard sites and I think that some of those vanguard sites were putting physios into GP practice as well so I don't know that we were necessarily the first but certainly that publication was the first and when was that publication the publication was 2016 okay so you know you're talking sort of almost you know good eight years nine years you know getting close to a decade that I've been thinking about FCP now yeah and I think the other thing that really runs in parallel and is still really interesting you know there was clearly this interest that I had about the voice of the medical profession just took me down a line of thinking about sort of sociology of the professions which is really really interesting you know where professions come from how they emerge when I spoke to you guys a couple of weeks ago on the on the slides there were a couple of links to a really interesting Royal College of General Practice sort of series of small personal opinion documents about how general practice evolved from the apothecaries and the grocers and the barber surgeons of the 1800s and how they managed to sort of corner that marketing. So I had a real interest in sort of sociology of the professions and that still sort of exists now and you can see you can see that in the really, again, the strong narrative that's happening at the moment around physicians' associates in general practice. And, you know, that in itself is interesting. But, you know, and again, in terms of the sports rehab guys as an emerging profession, you know, I'm sure there's lots of work going on in the background to sort of professionalise that group of people as well. So, you know, it's really interesting how FCP sort of fits into that sort of sociology of the professions narrative as well.

SPEAKER_04: 13:10

Excellent. And obviously you mentioned this a little bit during our lecture a couple of weeks ago, as you mentioned. But what were the, you obviously work with lots of general practitioners, and what were their views, what were their views on the whole FCP

SPEAKER_00: 13:26

rule? Yeah, yeah, and that's really interesting. So I think that a lot of my research has been qualitative. And I love qualitative because you can dig a little bit deeper. You can sort of try and work out, you know, not just if things work or not, but why they work, where they work, who they work for. And that's right, you know, the sort of reason behind it. But even so, I think that it still sometimes leaves you with, you know, either unanswered questions or it leaves you with sort of intuitions that, you know, you've still only got a partial knowledge, even with sort of qualitative inquiry. So I've spent spoken to quite a lot of GPs and on the face of it they are on board and really appreciative and supportive of the FCP agenda you know I think that there's a real acknowledgement that physiotherapists bring a musculoskeletal expertise into general practice I think that there isn't really a massive amount of evidence that I'm aware of that demonstrates that they have noticed a particular particular change in their caseload experience so I don't know that GPs where FCP has been implemented say oh I see very very few MSK patients now I think some spoke about noticing a reduction but generally the capacity of FCP where it has been implemented isn't sufficient to cater for that 30% demand of patients who have an MSK problem so it means that it's the potential of it still isn't being fully realized but back to your question i think generally gps are supportive of fcp um but i think again if you look at this sort of literature around the sociology of the professions very often when the dominant profession um engages with a change, like FCP, they're prepared to give away elements of their role but there are boundaries and lines in the sand that they draw in terms of, but I'm not prepared to give away that. And I wonder whether that's what's happening with the physician's associate, because essentially physician's associates have been purported to be almost mini-GPs, and that might be encroaching even further into the GP domain than FCP, which is obviously just MSK-related problems. But interestingly, some GPs really acknowledge that they had problems a very poor skill set around MSK so they thought well this is fantastic because the patient's getting better care but there are some GPs who really love MSK and that's part of their specialism and then there are some GPs who said well it was quite nice to have a sprained ankle come in in and amongst the sort of increasing complex caseload that I see it was almost a bit of light relief and to lose that would be you know a bit of a burden because because it would mean there would be no light in that real sort of complex caseload. And it's going to

SPEAKER_03: 16:44

be more sort of complex.

SPEAKER_00: 16:45

Yeah, yeah, yeah. But some GPs, again, were really pragmatic. Yet, if this happened to its full potential, my caseload as a consequence would become more complex. But that's what I see my role as, as a GP. Those are the patients that I should be seeing. And if other people can deal with the more straightforward things, then that's probably right that they do that.

SPEAKER_04: 17:09

And I think you mentioned again in that lecture that some, did some GP suggest that if they don't use it, you'll lose it, that kind of MSK knowledge. They are MSK specialists by trade, but did some suggest that as well?

SPEAKER_00: 17:25

Yeah, absolutely. Yeah, yeah. And I think again, so yes, they did say that. And I think again, you know, although the headline is 30% of a GP's caseload might be MSK, it's not as clear as that. So some patients will come in for example, a diabetes review or another health condition. And as they're walking out, they might mention, oh, by the way, doctor, I've got this stiff shoulder. So, you know, some people who present with MSK problems might not present with that problem as their primary reason for going. It might be the second or third thing on their list. So the GPs will always have to have some capability in terms of managing MSK. But, yeah.

SPEAKER_03: 18:09

And so originally in sort of your idea, how did you see it working in terms of the system? Would patients just go straight in and see this FCP practitioner? Would they be screened first to work out which way they needed to go? How did you see it working and how did it start to work?

SPEAKER_00: 18:29

Yeah, yeah. So I think the other thing that was good about the model of our very first evaluation, there were a couple of things that were really relevant pertinent and still are which have been somewhat diluted but one of the things was that we were really strict that you know the patients hadn't seen a GP before so they were true first contact patients and that was always you know always my thoughts around it in fact my thoughts around it were that we got self-referral to work in the way that it was designed to work. Like I sort of described before, that patients wake up in the morning with a stiff neck or a stiff shoulder, whatever it is, and they think, right, I need to book an appointment to see a physiotherapist. And what my research showed is that that's not the case. People wake up with a stiff shoulder, a stiff neck, and they think, I've thrown the general practice and book an appointment. And historically, what that's meant is they've seen a GP so the GP is so deeply and strongly embedded in our social cultural way of thinking that you know to get people to shift to think physiotherapy first is clearly a very very stubborn thing to change otherwise self-referral would probably have worked more already and it clearly hasn't done so my very very original motivation was to get those 1200 patients or so a month that go to the Mosaic CityCare MSK service to go there first without going to see a GP. So to a certain extent, As a profession, we've probably overcomplicated it because we've introduced something that's new, FCP, and you sort of think, actually, if you'd almost put an embargo on every GP practice, that if somebody rocks up with an MSK problem, you directed them to the self-referral physiotherapy service, which I'm sure did happen to a degree, then we could have almost circumvented the need for FCP because they would have used services that were already there. So

SPEAKER_04: 20:42

there's kind of a need for a little bit of knowledge from the admin staff as well, really, isn't there? I've come in with this problem and I've identified that MSK condition and they can signpost to the FCP.

SPEAKER_00: 20:54

Yeah, absolutely. So the way that has been implemented is that we've advertised, we've created and we've recruited to these new roles in GP practices, which on one hand is really, really appropriate because it's theoretically closer to home for patients to go to their local GP practice rather than going to down the other route of sort of, you know, really making sure that we utilized self-referral. We've decided to do it FCP wise, which is, you know, probably created a number of, problems in terms of recruitment and retention and workforce and stabilising or destabilising MSK pathways. But you're absolutely right, in the way that it has been implemented within GP practices as first contact practitioners, then what we found and what's been found repeatedly is that fundamental to the success of that is the role of administration staff in signposting. And when that first started, they quite understandably were really anxious about that. Will I send the right patients? Will I send the wrong patients? What happens if I send somebody who's having a heart attack and complaining of shoulder pain to see the physio? Will I get the blame for that? So it took quite a lot of settling down and embedding for the admin reception staff to become more confident about signposting.

SPEAKER_03: 22:19

And I think going back to that culture of changing, of going to see the GP to the physio, obviously we have an ageing population, if you said sort of to an elderly person, oh, I'm going to, I need to, I've got an MSK problem, go and see a physio. I think they'd understand that more than I've got an MSK problem, go and see an FCP.

SPEAKER_00: 22:45

Yeah, yeah, yeah. So a big part of my PhD was talking to all stakeholder groups about awareness and understanding. And I was interested in two things. One, awareness and understanding of physiotherapy. And secondly, awareness and understanding of self-referral and obviously leading on from that FCP and what I found was both of those things awareness and understanding were really really poor in the patient population they were very very poor but you know within the GP population they weren't great either so patients would say yes I've heard of physiotherapy so I think physiotherapy has got an advantage in that from a professionalisation perspective they're a very well established profession and physiotherapy as a profession has done very well to be embedded within national health services in a way that you know other msk professions if we're thinking specifically about msk and i think that's probably because physiotherapy has got the breadth that it's got in terms of other sort of conditions specialities as well but if you sort of said to patients have you heard of physiotherapy are you aware of it they had but if you said to them what do physios do and i think this is probably changing i think it was already an indication in my phd that it was changing But, you know, some of the things that people described where they got their knowledge from about physiotherapy was on the television. So, you know, if physiotherapists are on medical problems like 24 hours in A&E or casualty or physiotherapists running on the football pitch. And I think that still does pervade now, those sorts of impressions that people have. The other strong form of information was if somebody else has had physiotherapy that they know so they got information from that and that can be really good or that could be really bad word of mouth is incredibly powerful but yeah awareness and understanding of physiotherapy self-referral was even worse and FCP was probably non-existent to that time but this was right my PhD was right at the beginning of the FCP initiative so you would expect that people's awareness and understanding that would be pretty much negligible really

SPEAKER_03: 25:03

and I think hopefully that's changing now because the younger generation that's coming through if for example if they're watching sport on TV the football or whatever and they see someone running on the pitch they're like who's that and most people I would say in that younger generation are like that's a physio so I think they are the culture is starting to change and that physio is becoming more of a well known profession so hopefully that can help with the FCP role and that people wake up with a sore ankle and then they're like oh I need to go and see a physio

SPEAKER_00: 25:39

yeah yeah I hope so I hope so and I think that you know One of my frustrations, I suppose, is I had a vision of what the potential was for FCP or in even simpler terms, what the potential was for self-referral physiotherapy. And, you know, I had conversations with the CSP and I think they did have at one point a tagline of think physio or physio first. And I think that that was fantastic, you know, way of pushing forwards MSK physiotherapy to try and get that shift in culture so that people did think you know it's an MSK problem I'll go and see the physiotherapist so I do think that there is the potential to change my frustration I was going to say is that the speed of that change is slow and I suspect that that's just normal I suspect that sort of significant change is just normal and it just requires patience and you know you can see Or you can imagine that the longer physiotherapists are part of a general practice team, then the more that change will take place, the more people will come to recognise and see physiotherapists within their general practice and what they do, and they'll make those choices over time. So I suppose I've said to myself lots of times, just be patient. This is going to take some time to change. So that's on one hand. And then on the other hand, There's frustration that our first paper was published in 2016. The additional roles reimbursement scheme was launched in 2019, I think. And the plan was that by April 2024, this year, everybody in England would have access to FCP. So, you know, in less than, well, what, in less than 10 years, it went from an idea to a national implementation. And I mean, in research, they sort of, I think the often quoted statistic is from laboratory to clinical practices plus 20 years. So on the one hand, we need to be patient. We need to let time pass for these changes to become established. And then on the other hand, someone has made a decision to implement something so, so rapidly and probably without as much thought as was required so you know you've got those two things sort of sitting paradoxically against each other you know let's be patient let's let the public adjust to this change oh no let's do it today and it's like I think through that rapid implementation that hasn't perhaps been as well thought through as it could have been it's created some problems in and of itself okay and moving on to

SPEAKER_04: 28:44

kind of what do you have any ideas for how the FCP role will develop going into the future or do you have any aspirations for the role or obviously how it might all come along in the future

SPEAKER_00: 28:59

yeah yeah yeah so I think that Yeah, so I don't know, because I've not spoken to the guys within the MSK service that I worked with, whether they have noticed a change in the proportion of people who are, through their own volition, using self-referral. So, you know, if we think that people are becoming more aware maybe of physiotherapy, then that might not just mean that people are using FCP, it might mean that people are using pre-existing services like self-referral. I don't know whether that's happening, which would be great if it is. In terms of where I see it going, I think that it's still pretty unpredictable at the moment. So last year, there was the NHS workforce plan. FCP is described in that as enhanced practice rather than how it has always been described previously, which is advanced practice. So enhanced practice is, I suppose, in simplistic terms, like a step down. So it almost feels like it's a slight dilution of the sort of clinical expertise that was Not necessarily by me, but was advocated by physiotherapy as a profession in terms of the vision of FCP. And I suspect that's probably because of the challenges that have been created almost by FCP being at this super advanced level in terms of the workforce. Because, you know, I think that... the really rapid implementation of very, very senior experienced roles in general practice has created a bit of a gap behind it in the pre-existing MSK services. Does that make sense? Yeah. Yeah. So I think that maybe by slightly lowering the bar, if how I read the workforce plan is accurate, means that it opens up recruitment into FCP posts a little bit more widely so it's not setting the bar quite at band 7, band 8 it might be sort of just lowering that bar a little bit which might sort of on the one hand be good for recruitment but I think you obviously just need to be sort of cognizant of what that might mean clinically. Personally I don't think that's a bad problem we did a follow up evaluation from our first evaluation which was quite interesting because the commissioners, based on our one-year evaluation, wanted to implement it across the whole of Nottingham City. Now, my employers at that time, quite understandably, were cautious about recruiting lots of Band 7s into these posts, so they offered the commissioners the opportunity to deliver that service at Band 6 level, and that was delivered for, I'm not sure if it was 18 months, two years, and the outcomes were very similar to the original evaluation. There were good clinical outcomes. The onward referral rate was very similar to the previous band seven FCP evaluation. And as far as we know, there were no adverse incidents. So, you know, you could say that the FCP service could be delivered by more enhanced practitioners rather than advanced practitioners. But when I spoke to Jack Chu about this, he had worked with our team and he sort of you know those guys who were working as band sixes anywhere else in the country there would have been band sevens anyway they were very very competent experienced practitioners i still think personally that if you flicked a switch and all of those msk patients who are currently going to see a gp started to use a self-referral physiotherapy service that exists in nottingham city they could in theory see a band five a band six a band seven or a band eight and i I think that would be fine. And the reason I feel confident saying that is because there are structures within that team that exist to support the less experienced staff. They have a senior. They have reviews of patients. If there are any concerns, they can discuss them. So that, I think, is... one of the things that's coming out of the FCP is that they feel very isolated. They don't feel that they've necessarily got those systems of support there that provide that reassurance and that protection from the risk and uncertainty of seeing patients who are walking off the pavement. I don't think that's unresolvable. That exists in self-referral services already. So again, we've just created almost a little bit of an additional complexity and complication Does that make sense? That makes sense, yes.

SPEAKER_03: 34:08

And so you mentioned obviously one of the problems there with the FCPs feeling isolated and lack of support. Is there, were they being rolled out so quickly nationally as you said, is there any other problems that you've heard about or encountered with the FCP role?

SPEAKER_00: 34:24

Yeah, so I mean there's all sorts of practical things. So FCPs will describe going into GP practice where the electronics record system is a different one to the one that they're used to so there are those sorts of learning things sometimes they'll go and because they're not employed by the general practice they've not got access to the general practice module so they have to work on a module that sits outside that and then there's copying and pasting of records that has to take place some physiotherapists don't have access to the electronic diagnostic pathway so although in theory they should have the skills to refer for MRI scan and x-ray they can't because they've not got access to the systems so there's some practical issues but then again you've got these more sort of personally related issues like the isolation and this isn't universal I mean some physios describe having fantastic support from GPs so some physios will say at the end of the day GP will sit down and go through my day with me and they'll sort of support me So this isn't universal, but some physios might be working half a day in a GP practice a week. They walk in, they say hello to the receptionist as they go. As they arrive, they go into the room and then they say goodbye on the way out. And that might be the only interaction they've had. And that might be an extreme example, but I'm sure that that does happen. So it is quite isolating. And then the other feature that is seems to be coming out from work that other colleagues have done is around sort of what we call or what's called the undifferentiated patient so this is a patient who walks in off the pavement they've never seen anybody so you've got to you know work really quickly because the appointments are generally a little bit shorter you're looking at maybe 20 minutes you know is this something that is MSK or is it something else masquerading as MSK so I think there's some evidence around sort of the challenges of dealing with that uncertainty that exists and I think the busy nature of the clinics, the isolation, the uncertainty is leaving or is making some physiotherapists wonder whether it's a job they want to do in the long term. Certainly, locally, our experience was that physiotherapists who started working as FCPs three or four times a week very quickly wanted to reduce their FCP commitment, which was really... possible within our service because they had split roles. So they did some MSK, but they also did some FCP work. And you could, you know, flexibility inherent in that allowed them to reduce their FCP hours and increase their MSK hours. But the backlash of that was we couldn't recruit to fill the FCP hours that they left behind. So real recruitment issues. So yes, burnout is a feature, I think, as well.

SPEAKER_03: 37:32

Yeah.

SPEAKER_00: 37:33

Interesting. you know,

SPEAKER_04: 37:34

Yeah. So for our students and society member listeners, for those interested in going into an FCP role or something similar, what skills would an FCE or would you like to see an FCP practitioner, what would you need to, what are your tips, what are your tricks for going down

SPEAKER_00: 37:57

that route? Yeah, well, I mean, I think it depends on what the model is like. So, you know, let's say the model merges and changes and it becomes a bit more like like self-referral, then I think you're looking at making sure you've got your basic MSK skills. But that is, certainly as a newly qualified physiotherapist, that's sort of incumbent on you working in a team that's very supportive. I think otherwise... you are looking at the way that it's positioned in general practice at the moment, that it would be something that you'd be thinking of moving into sort of a couple of years down the line, particularly if it is more of an enhanced role rather than advanced role. I think if it stays as an advanced role, you're looking at sort of five years or so before you'd be in a position to do that. So I think it depends a little bit on what the model looks like. I think that, again, there has been a little bit of work done around what are the requirements for graduate training to equip them to fcp and i think that physiotherapists who are working fcp positions say pretty much what i've said that you know you unfortunately need to get that experience to put you in a position to be able to do it but they were able to also say that you know the basic assessment subjective and objective assessment skills you know provided them with a real good foundation i think that what's fantastic for you guys is you know that the talk I did a few weeks ago, that's the first time I've been asked to do that. So I think that probably inherent in that is you've been exposed to it now in a way that years before haven't been. So you've already got it if you've not looked at social media or frontline or whatever. You've started to have it a little bit closer to the front of your mind now as an option. So I think that actually starting to think about it actually starting to read some of the evidence around it, actually starting to anticipate some of the challenges, you know, the shorter appointments. Those sorts of things are all things that are just probably worthwhile exposing yourself to and starting to think about and then, you know, getting that experience. You know, the other thing that physiotherapists have said is that they found it really useful having gone through some broader rotations as a sort of less experienced physiotherapist physiotherapists because obviously in general practice there's so much comorbidity you know the MSK problems are hidden within and amongst lots of other health conditions as well so there's benefits from from just taking your time and getting getting that experience and and you know the I think again the evidence is suggesting you know the the study that Nikki Walsh and her team did down in the south of England is the only comparative study, really, about FCP. So they looked at FCPs who'd got advanced skills or enhanced skills, so injections and prescribing, and more standard physiotherapy, so they hadn't got those advanced skills. I don't think they found any difference between the two. So I think those extended scope skills are the cherry on top of the icing, on top of the cake, really. I mean, the one thing that came up time and time again from the physiotherapists I spoke to in FCP roles that they felt they would benefit from having more training in was around mental health. So I think, again, having a real good understanding of the BPS model would be certainly, I would strongly advocate that. And then I think obviously any additional training that you want to do around mental health or MSK conditions.

SPEAKER_03: 41:51

So you've answered the skills and experience you need and how you can go about getting into the FCP role and pathways with MSK experience and things like that. Just finally, is there any other general tips for students that you'd give from all your experiences in your career?

SPEAKER_04: 42:09

Or if you were just graduating today, what's one tip you would give yourself looking back as a bottom line, as finishing off?

SPEAKER_00: 42:20

Oh, gosh. That's a good question. Yeah, that's a good question. I think... I was thinking about this last night, and I remember doing one of these psychrometric tests, and I don't think it was the Myers-Briggs one, which is one... But I came out as, I think the classification was what was called a plant. And the plant was the person who sat in meetings and said, why don't we try this? And so almost like the ideas person. Now, the downside of that is I didn't come out as what was called a complete finisher. So for a long time, I thought I can never see a project through to the end. Now, hopefully I've started to, from a personal perspective, challenge that a little bit because I have done some things through from start. from start to finish. But the one thing that I think that, you know, is innovation and opportunity. And I would encourage anybody, I think physiotherapy is a fantastic profession in terms of providing opportunities. And, you know, I would just say, you know, keep your eyes really wide open, keep looking left and right and seeing, you know, what's happening around me, you know, what's happening around me in the profession, what's happening around me socioculturally, what are the opportunities for me to sort of really you know extend myself um in an innovative, original way. Excellent. Yeah, so that would definitely be my... And I think, as I say, I think as a profession, there are so many opportunities. So, yeah, you know, absolutely take the bull by the horns, guys, and go for it. And this is indicative of you doing that. I mean, this is a bit different. It's fantastic. So well done.

SPEAKER_04: 44:06

Perfect. Thanks very much. Yes, no, thank you very much for coming on, Rob. Thank you.

SPEAKER_00: 44:10

No, it's a pleasure. Thank you for having me.

SPEAKER_01: 44:14

Shall not have gone away