FCP Podiatrist Richard Keating, now two years in the role, explains how his work has helped free up GP time and what the requirements are for networks wanting to hire a podiatrist
Northamptonshire Rural PCN is a group of five GP practices all based within a rural setting.
The network serves just over 50,000 patients, with a population skewed towards an older demographic, but that also includes a significant number of commuters. Patients can experience some difficulty accessing specialist services, which are often located in urban centres.
Our PCN team currently comprises a core team of two social prescribers, three care coordinators, nine pharmacists, one pharmacy technician, two physiotherapists and, of course, a podiatrist.
Why did the PCN recruit a podiatrist?
The network recognised that a significant percentage of both chronic and on-the-day demand related to musculoskeletal (MSK) conditions. It felt this could be managed more effectively and efficiently by developing a primary care MSK team and expanding on the First Contact Practitioner (FCP) model, with patients navigated to either physiotherapists or podiatrists, as appropriate. By coordinating clinics in this way, it was hoped it would allow patients faster access to both diagnosis, and also comprehensive and timely management advice.
However, once I was in post the reality was very different and the PCN had to adapt. We soon noticed that having an MSK specific focus was quite difficult to achieve from a triage point of view. As a result, the criteria for a patient being booked in to see the FCP podiatrist (myself) was broadened out to include them having any foot/ankle problem (from plantar heel pain, ingrown toenails to foot ulcers, for example).
My role still has a strong MSK focus as a result of reduced secondary care provision in our area. But ultimately, the role is about streamlining and improving the patient journey, removing barriers and improving equality of access to specialist services so that demand on GP appointments is reduced.
What did the hiring process look like?
Since podiatrists are experts in all aspects of foot and lower limb function and health, they can have quite wide-ranging subspecialties from MSK to high risk foot management. I was recruited for my strong background in MSK medicine although the desired skillset is something that will vary geographically between PCNs, as needs differ.
That said, key requirements for the role are:
- A BSc or equivalent in Podiatric medicine
- Must be a registered member of the health care and professions council
- Evidence of working being able to work at Master’s degree level in the practice, or be willing to undertake this on appointment
- Must have experience of being able to operate at an advanced level of practice
- Must have access to appropriate clinical supervision.
The job was salary mapped between Band 7 and Band 8 on the Agenda for Change pay scale and posted on the NHS jobs website.
What does the podiatrist do for the PCN?
Since all the practices are in rural settings, a central hub model does not meet the PCN’s needs. Instead, working full time, I spend one day a week at each practice. Receptionists can book patients directly into my diary, either as a first contact or secondary contact when a GP or other clinical staff member feels the patient might benefit from my input. Each appointment is around 20 minutes long and I see, on average, 18 patients a day.
As you’d expect in primary care, I see a variety of cases, with a variety of needs. In any one day I could be dealing with plantar heel pain, first MTP joint osteoarthritis, a suspected case of inflammatory arthropathy, an ingrown toenail or a newly developed complex foot wound.
How I address problems depends on patient need but could include simple interventions such as self-management advice, signposting for orthoses, or advice on footwear. It may also involve me possibly performing landmark joint injections or nail surgery as per the primary care contract.
For the most part, I am able to work autonomously. For example, I assess, treat, swab, dress, request blood tests, prescribe antibiotics (I have completed an independent prescribing course), arrange for imaging if needed and, where appropriate, refer cases to secondary care – all without the need to involve aanother member of the GP practice team.
What support does the role require?
Mostly, I work autonomously. However, my role needs supervision, as is required under the HEE’s FCP Roadmap to Practice, which are duties that involve GPs. A designated GP at PCN-level spends one to two hours a week to help me complete the Roadmap. Normally, it’s expected this would take 12 months to achieve, but it’s taken longer for me since implementation of the Roadmap was delayed.
I have a nominated GP working with me day-to-day who provides a formal debrief if needed at the end of each clinical session until I’m ‘signed off’ as having demonstrated competency on the Roadmap. At first, I needed allocated and protected time for this but now a debrief usually only takes a few minutes.
There are also other commitments required from a GP, such as completing a consultation observation tool (COT) once a month and clinical examination and procedural skills (CEP) sign-off. This formal support is needed only during the process of completing the roadmap.
The feedback from the PCN is that supporting the role does require investment of time but the benefits a podiatry service bring outweigh these extra demands.
How has a podiatry service helped practices so far?
Audit is a required component of the Roadmap. Data on my role demonstrates that in around 51% of cases I was the primary contact for a patient’s complaint with the other 49% coming from GPs, practice nurses and PCN colleagues.
It also showed that 56% of all appointments were MSK-based problems and 35% were dermatology-centred issues. In only 3% of cases was support required from a GP (from a prescribing standpoint). At last audit, I was managing 77% of patients within primary care and referring 23% on to secondary care. Compared with other PCNs nationally, the proportion managed in primary care is fairly similar but destination of referral varied greatly depending on geographical location. We presume this is a result of secondary care provision and pathway differences.
The audit concluded that with the present way of working, having a podiatrist in place for first contact could save more than 80 GP appointments a week.
This audit data was also used to contribute to a collective national audit project led by the Royal College of Podiatry, which gathered information from several sites. It revealed that one FCP Podiatry service in South Tyneside was the primary contact for patients in 80% of cases. This suggests there is scope for our PCN to improve and therefore for more GP appointments to be saved.
Feedback from primary care colleagues about the podiatry service has also been favourable. They report feeling under less strain, no longer having to deal with common conditions like plantar fasciitis, which frees them up to focus on problems that require their specific skills.
Colleagues have also found taking a more team-oriented approach has benefited their learning.
How has the role developed since you were first hired?
As already explained, soon after I started the job, we quickly made changes to triage and the criteria for being seen by me, so we could provide more effective care navigation.
Last year, I completed an independent prescribing course with support from the PCN, and I have noticed a reduction in the need for support from medical colleagues as a result, including when managing complex problems.
I will be submitting my roadmap to practice in the next few weeks, which should officially cement my autonomy in the role. I have since reduced my role to a part-time one so I can pursue other interests outside of primary care. However, the PCN decided there was a valuable need to have a full-time equivalent FCP Podiatrist in place because the service is so effective. A second FCP podiatrist has now been hired, so we will job share.
Richard Keating is an FCP podiatrist at Northamptonshire Rural PCN