Transcript

Hello ladies and gentlemen, welcome to Advanced Practice Weekly. Today I’m joined by two very special guests, Aileen and Becky from Hounslow Community Healthcare, West London Trust.  They’re going to be talking to us today about the work that they’re doing in a community. So we’re going to do a quick introduction of both of them and then we’re going to get straight into some questions. So Aileen, would you like to start first?

Sure. Thanks.  So my name is Aileen Robinson. I am a consultant physio and I work primarily in FCP. So first contact role in primary care. But I also have a split working in an MCAT clinic as well. So the musculoskeletal clinical assessment and treatment service on the Hanselow side.

Lovely, and Becky.

Good morning, I’m Becky Lydon. I’m the consultant physio in Hounslow MSK service. I work closely with Aline, providing care in the community. Wonderful.

Okay, so Aileen, would you like to just tell me a bit about your background and what brought you to working in physiotherapy, MSK, community work?

Yeah, so I’ve been a physio for 24 years or so. I worked 10 years in the NHS, then had some time in private practice and working in sports for 10 years, and then came back to the NHS to come into an advanced practice role, having gained similar experience actually through private practice and through insurance companies and case management work, but very much coming back into advanced practice and applying those skills that are gained kind of in another environment.  So looking at kind of work across the four pillars, but very much that kind of clinical advanced practice delivery.

Great.

Becky? I have worked at lots of different trusts across London having always wished to work outside of London and but what that gained me is lots of experience of different ways of trust working.  I think as I fell into MSK because I’ve done a sports science degree previous which actually inspired me that that’s where I end up in the MSK sort of setting and worked alongside some of our sort of leading consultants with who have an excellent horizon scanning from guys in Thomas’s and that sort of they were some of the early instigators of extended scope practice which was the pre-empt to the advanced practice where you were a clinical specialist and then went off into doing again women’s health and sports physio alongside my NHS role then went private to experience that for a while and realized that actually the NHS offers you lots of opportunities to develop you have much closer links with other services and I’m glad I came back and went similar to Aileen went back into an advanced practice role and I’ve been working about yeah 20 years or so

I think sometimes when you’ve been in NHS for a long time period it kind of draws you back in, doesn’t it? As you said, the developmental opportunities and the funding and stuff that’s there doesn’t really exist in those other areas. Great stuff.  Okay, so let’s talk about what you guys are doing now. Do one of you want to tell me, we had a chat a few weeks ago about the services that you’re providing. We were very interested in sort of highlighting the great work that you’re doing in the community. So do one of you want to tell me about the service that you’re currently providing and why it’s interesting and why it’s innovative.

So our core service is that we’re doing first contact practitioner work. So we are delivering MSK expertise in primary care and probably slightly different to a lot of services. We have APPs in those roles, so advanced practitioners in those roles. So it becomes a hybrid service where actually we’re not having to refer into a community or hospital based service for patients to access workup. We can do that from primary care and fast track patients through the system. So very much avoiding placing people on unnecessary waiting lists.  We can start their rehab kind of very early in their journey from that first visit to their GP practice, not having to wait necessarily for a physio appointment, but there are only a few of us. So we probably only see about 30 percent of the MSK workload in our kind of primary care catchment area. But we are developing our services, so offering things like injection clinics again, so that we can do that early workup, treat patients who don’t need to be referred in and offering them the correct services just much earlier in their journey before things maybe become chronic. And we’re also looking, I guess, with the evolution of neighborhoods at developing services like pain cafe, where patients who maybe have chronic pain and aren’t necessarily engaged with lifestyle kind of change or getting the social support that they need that that we know impacts their health, allowing them access to that kind of much more easily and kind of much sooner, like we said, in their journey. So again, offering the right services at the right time and bringing kind of partner like services together to support patients kind of in a one stop shop.

Wow, that’s loads isn’t it? That’s a huge amount. It’s so much.  And so for these patients that are coming in, so when they call the GP practice and say, okay, I’ve got a problem with my knee, for instance, will they see one of the practitioners? Will they be directed straight to a physio? How would that work?

Yeah. So ideally it should be that they call reception. The reception will say to them, actually, the FCPs are our musculoskeletal experts. The GP would recommend that you see one of them instead.  And so long as we’ve got availability, absolutely, we will see them. We’ve got more time. We’ve got 20 minutes in our appointments. So we can thoroughly assess. Then if we decide that the patient actually, I don’t know, doesn’t have an MSK condition, we can send them off and direct them on the correct stream because I think that’s part of advanced practice in primary care is dealing with that undifferentiated undiagnosed pathology. But if they do have an MSK issue, we can certainly kind of do work out by way of MRI, x-ray, bloods, whatever is indicated, and then kind of progress their care from there with things like that we’re developing around the pain cafe. The idea there is that actually we know that patients kind of end up looping through primary care into MSK services and actually not really progressing. So it’s looking maybe at the broader kind of social determinants of health and how can we address those because everything’s so intertwined in terms of physical health, mental health, social, emotional, and how do we best address that for the community that we’ve got.  And so that’s what we’re developing at the moment is trying to pull everything kind of under one roof and in one location for patients to access and that will have a different kind of referral model in that GPs and FCPs will be able to kind of refer to us for that.

Okay, there’s a lot going on there, isn’t there?

Job doesn’t get any smaller, but that’s the excitement, I think, of advanced practice.

Yeah, absolutely. And as you alluded to, there’s that undifferentiated care, it’s seeing the, you know, completing that whole journey for that patient.  And by them seeing you first, if it does turn out to be an MSK problem, which I suspect most of the time it probably is, if the triage at the initial stage is done correctly, then we cut out that middle referral pathway, don’t we?

Yeah.

Okay, Becky.

From out of my perspective in the MSK service, we sit in a community setting, so we are weirdly on site of a hospital, but we aren’t actually fully linked to the hospital. So it’d be like being in any building in the Hounslow area and patients come to see us there.  I was involved as part of the advanced practice cohort of developing the initial pilot for FCP, so wholeheartedly believe and support aliens roll out in the community as being like one of our key factors of getting into patients early for that prevention, early rehab. Again, we’re in the community, so what we’ve done in terms of trying to innovate, we have those clinics where patients could, we’ve got self-referral. So again, we are having to do a similar sort of MSK integrated review of patients and look whether they’re on the right pathway if they turn up in our MSK clinics. What we’ve done in terms of innovation, I believe, and most recently, post-pandemic, I think people have been more inspired that it’s worth looking at new ways of working, so that’s the positive of the COVID pandemic, is that we’ve run some community assessment days, which are where we’ve gone out to the community. It’s based off the West Sussex initial project, and that’s looking at very similar to the FCP smaller version of bringing everything together. Patients literally, even with an MSK problem, have so many other factors that are going on, particularly with the core 20 plus five, which is the population health data. It demonstrates that our patients, particularly in Hounslow, have lots of other factors that influence whether they would adhere to getting better and whether MSK is their main issue, often it isn’t. So the community assessment day brings together, again, the same. We’ve sort of focused on having low back pain as our primary one. We’ve worked alongside the sure trust and sort of job aspect of things, so bringing in social prescribers, which are people who can link patients to charities, give them advice on things that matter in their life. We’ve also linked with mental health services so the talking therapies that are available, really trying to bring in everything we think affects the patients. We’re looking to roll that out to osteoarthritis patients, really getting to the community because we realise with, especially with the NHS plan of trying to be more in the community, it’s accessibility as much as anything. So feeling inspired from Anthony Gilbert and Rishi and Navasari’s work out in Royal National Orthopedic, they’ve been going to food banks and homeless centres because patients often don’t know we exist. They don’t know what we offer. They don’t know that we have this amazing access to pathways to secondary care if they need it, but I think the reality is our experts are sitting a lot of city in secondary care and so sitting in a community setting alien and I are lucky that we can actually start to influence because of our advanced practice base we’ve got not only clinical expertise but we’re looking at how we develop other staff, looking at the current research and the education opportunities so that our service is actually really moving forward in a really strong way using leadership as that model which the NHS fully believe leadership has a crucial role.

So are there any particular innovations or service models which you’re involved in that reflect these shifts, for example, virtual triage, remote rehab or integrated MDT clinics?

We’ve developed a virtual MDT which is fantastic with our secondary care colleagues for community spinal patients who would have gone on to a routine waiting list, they wait for six to nine months as a minimum to be seen for an opinion.  Now we’ve got it virtually we’ve managed working conjunction with our North West London other boroughs which is again collaboration which is fantastic and we take patients and their history and their scans and pain consultants and neurosurgeons work together which is also an amazing feat of bringing those patients together so that they can review patients and give us ideas of management so that patients aren’t sitting for nine months to wait to decide what’s going to happen and we’re hoping to roll that out further to pain MDTs and possibly rheumatology MDTs which are so that we are within the community managing patients early.

Just out of interest, what’s that waiting time been brought down to now from somebody with a spinal problem?

Currently, they’ve got to wait to come to our MSK service, but if they’re lucky and they see our FCP colleagues, that’s quite a quick routine within a couple of weeks to see the FCP and a few weeks to come and further see our Visio department. They have an MRI if that’s indicated, normally we need to do that. So that’s gonna take a couple of months. So within three months, they could be on the list to be discussed and a decision made. So that’s a massive difference because previously they would have had a three month, they would have the same workup and then another nine to 12 months wait to see a consultant.  So it’s a big change. It’s also impacting, we hope, the waiting lists of the pain and neurosurgical lists. So they’ll have less sitting on there. So ultimately it will speed up their ability to see patients in the long run.

So what kind of patient groups do you typically see and how do you see your role contributing to their prevention, rehabilitation and keeping people out of hospital? What are the types of patients that you see most of and the ones that you think you probably have the biggest impact on?

Our patients are screened in primary care just by the reception staff. So it’s what seems like an MSK problem on the face of it. So once we have decided and obviously keeping patients safe, we’ve decided it’s not a sinister or serious pathology, although we do encounter those as well. So we need to be aware of those pathways. But on the whole, it tends to be the most common things we see are probably back pain related across all age groups.  Lots of knee arthritis. Then I’d say we see lots of kind of occupational related kind of injuries, shoulder pain, neck pain from people sitting at desks or doing heavy lifting, but across the spectrum of kind of adults, kind of ages. So for us, it’s 16 plus plus, but that’s 16 through to anyone who can come and see us in a GP practice. So that’s the kind of population that we tend to see. We’re in Hounslow, so it’s a very kind of culturally mixed population with lots of different beliefs and health care kind of literacy and education. And we need to be flexible in our approach to how we manage those patients really sensitively, because sometimes their ideas and our ideas are at opposite ends of the spectrum. So actually, it’s how do we bring this patient on a journey that doesn’t kind of offend them in terms of how we convey messages and how do we educate them so that they can take control of their own health care?  And so I think they’re the things that we start to then feed into prevention and rehab and through education. And I think it’s looking at in primary care, the other things that we link to are we will see a patient who might come, say, with a frozen shoulder. We can see that they’re diabetic and they’ve not had a diabetes review for two years, so actually, we can stream them through to kind of having those reviews, having their kind of medication reviews done, seeing the diabetes nurse or GP, whoever it is within their practice, looking at things like smoking cessation and then linking through with our kind of other colleagues in primary care. So social prescribers and then linking a lot from primary care, actually linking through to kind of healthy lifestyle programs. So just generally trying to promote healthiness and fitness within our population. People actually looking to improve their overall health rather than just being pathology specific.

Right. So yeah, I think very much with the MSK side of stuff, you have to look at the bigger picture, right?  It’s not just a, it’s not, we can’t just fix your knee. We need to look at everything else which is going on.

Yeah, exactly that. And the same with arthritis or whatever it might be.

Yeah.

we need to consider the arthritis and they need to get stronger or it might be that actually they need to go on a referral pathway through to see an orthopedic surgeon, but actually are there other factors that are there? Like you said, high blood pressure, cholesterol, all of those things that actually we know that if we can improve those potentially have an impact on their MSK health as well.

So let’s look at the 10-year plan. How do we see advanced practice from physiotherapy working towards those goals within the new 10-year plan?

I think that advanced practice, what it brings to the table is if you’re lucky, the job mapping for those roles includes time where you can do service work. So you can look at new innovations, you’ve got time to consider the current research, the NHS policies, so that you actually can be a bit more innovative, you can support staff to actually create new ways of working.  And very much with advanced practice level of working, you’ve got high level of communication skills. So when you’re looking at education, and for prevention, it’s how you use those high level communication skills to support patients to understand what’s going on, help them to be self motivated and self managing. They need motivational interviewing styles where they’re being supported to recognize their own goals.  Actually, that comes along with advanced practice and those that skill level, and where we sit, particularly Aileen and myself sitting within the community setting, we’re going to get access and those patients hopefully get access to us early. They’re not waiting for a long time and have not got lots of doors to get through to try and access that support.

Both of you guys are in quite senior positions within your trust. You are both running services.  Are you currently training or looking after or supervising any other advanced practitioners in training at the moment?

I think in FCP, well, we’ve got APPs working in FCP roles. We also have our band seven FCPs who are working at an advanced practice level, but just in the clinical pillar. And so it’s always looking at how do we develop them to kind of have experience and access the other pillars. So longer term, although they’re not in an official trainee kind of post, longer term, how do we develop them to be our APPs kind of of the future?  And so when was it last year? I did the multi-professional supervisors course through NHS England. I’m specifically designed for primary care. And that was really beneficial in terms of it was a very practical course. Take away kind of learning from every session and just be able to kind of go and use it in practice, less around the modules and the theories, but very much kind of practical kind of skill set. And so we are always developing our stuff when we have new starters and we have kind of, I guess, defined trainees. It’s then using those more formal models and frameworks to look at what are their learning needs and using those kind of supervision cycles and frameworks to support their learning and their development.

Following on from Aileen, we have also looked at supporting staff where I think the physiotherapy area, we’re sort of leading within how we’ve adopted the four pillars of working with the under advanced practice compared to our nursing compatriots. So Aileen and myself are working very closely with the West London Trust to support the nursing staff and other AHPs for their understanding of advanced practice and what that actually means in terms of job mapping across the trust.  Because actually, when you’re looking at supervision, it’s part and parcel of how do you maintain standards? How do you continue support? I’m personally supporting some of our Hounselow compatriots who are not directly in my team and looking at because they’re small teams, how do they get access to that support? Because supervision, including all the pillars of learning advanced practice is the crux of how you build the team and future proof, looking at where people are. So we’ve got apprenticeships opportunities. Yeah, I think that’s so we’re really sort of proactive and we really believe supervision is the way forward.

Are you doing any supervision for any other AHPs?

Predominantly, the other AHPs are more in the first contact practitioner PCN, in the GP sort of areas. Aileen has worked alongside a number of different practice pharmacists, et cetera. She can expand on that. But yeah, we sit alongside.  We’re advising the AHP leads within West London of what advanced practice looks like, why supervision is important, and the importance of mapping current needs requirement and where we are as a trust. So we’re in the early stages, I’d say, of making sure that’s on the agenda.

I think we’ve both been involved in completing the, the maturity matrix, the governance matrix of which kind of one of the pages is obviously one of the tabs is about supervision and then very closely linked with CPD. So we have kind of on an organizational level, we have areas that we know we need to improve on around supervision and probably the consistency of it across kind of particularly newer kind of advanced practice roles.  And I think there’s lots of supervision often in that trainee stage, but I think it’s borrowing the line from the matrix. It’s becoming an ACP is the beginning, not the end. And so it’s that kind of evolution over time and that support that we need to gain over time and how do we influence and get buy-in from our key stakeholders as to why it is important. Personally, I think it’s an area that we need to research more in terms of impact of advanced practice roles. We can look at theories and models and costs upfront, but actually, how do we demonstrate that longer term to really demonstrate the value of what we’re doing, to be able to take that away and.

But hopefully, you know, we’ll get some better data in the UK as things move on.  And obviously, the three shifts are about moving care to the communities, making better use of technology and focusing on prevention of sickness, not just treating it.

I think the prevention bit is actually like probably really key, isn’t it, across all of the shifts, because actually it’s preventing illness from happening in the first place or ill health from occurring in the first place, but also when it does happen, how do we prevent deterioration and co-occurring or consequential kind of health deterioration as well. And I think with the skill set of APs across the different professions, I think we bring the expertise and the skills to be able to support those patients early, which means in the community, not waiting for them, like we’ve said earlier, to sit on a waiting list to wait many months to maybe see someone in a hospital setting, but equipping patients with the knowledge and the skills really early to benefit their own health and supporting them to kind of sometimes make small changes, small step changes that over time really kind of add up, and having the flexibility to work with patients that actually it’s not a one size fits all, but being able to take the patient who’s in front of you has a very different presentation to the patient you’ve seen before, but being able to support them to kind of make the changes that are meaningful to them.  And I think with the knowledge and expertise and leadership skills of research and evidence based information that APs bring, I think they’re super well placed to kind of support all of those behaviour changes.

It’s quite timely, isn’t it? It’s about getting in there quick and trying to work out exactly what’s happening. Because if people sit on a problem for a longer amount of time, then it becomes much more difficult to treat, doesn’t it?

They ruminate and they worry the same as you and I do when we’ve got a problem and that’s normal but it becomes more of a problem the longer it is there so

Yeah, and many of our patients might have co-morbidities so they have one problem such as a MSK issue, but actually that impacts their diabetes control because they’re not walking it impacts their blood pressure because they’re anxious and worried so we sit well to also work with community groups and I think that’s like when we’re looking at like personalized care and allowing the patient to have control of shared decision of what they want to do and what they they want to happen and we’re also looking at how do they self manage themselves and education from an advanced practitioner is not only for the patient but possibly that out to the communities.  We’ve been looking at introducing community MSK hubs so that we might train those in the communities such as a Sikh temple if we’ve got so that we can access cultures that may we may not represent directly, but if we can support our gyms to provide information and care patients may not need to come to us. They can access osteoarthritis groups, balance groups, that’s already been set up to some degree and we’re looking to expand that so I think that’s already then using the community resources that we have working collaboration, we are already then hopefully preventing the need for further escalation and the technology behind things it’s great to have access.  We’ve got text messaging services. We’ve got access to ability to be able to send documents, information, websites to put videos and webinars out to patients and we’re hoping that we can expand that sort of repertoire so that there’s lots of different ways to access us rather than necessarily seeing face-to-face because we also have lots of patients that would be working in zero-hour contracts, tight timelines where they’re caring for others and they find it hard to access and get to us.  So actually using video appointments provides a lot more flexibility. So there’s loads of innovations we can do.

Okay, Becky, thank you so much. That was great hearing about all the different technology and innovations that you guys are doing.

No, I would just say to people who are considering kind of starting on the pathway, just go for it and get the support of your manager and your team around you. I put forward business cases to develop AP roles and when the opportunity arises, take the education and throw yourself into it because actually I think it stretches us in such a positive way and it benefits our patients.  So I would recommend it for people who are at that skill level to just kind of go for it and enjoy it.

Brilliant.

I would also recommend that staff who are more junior start to look into it already so they know where their journey is going to be, because it wasn’t there when we started in physiotherapy. So we hadn’t got that to aim for.  And so we’re almost doing backpedalling to sort of demonstrate we’ve got these skillsets. And actually, as soon as you start your career, you can start building your skills in leadership, education, research, and clinical, so that by the time you get to the level of thinking about becoming an advanced practitioner, you’ve almost got the evidence there, you hopefully have done a variety of courses. So don’t just focus on your clinical aspect, because I think physiotherapy and just anyone who’s at advanced practice, got so much to give in terms of their empathetic way of communicating with patients and stakeholders. And I think that can go a long way. And one day we’ll have about allied health professionals on boards of trusts. And I think that would push our agenda forwards even more for the benefit of our skillsets.

let people know that there is an amazing career pathway for most allied healthcare professionals now, whether you’re a physio or a podiatrist or an OT or a nurse or a paramedic, there are lots of different avenues for you to develop and really develop your career.  Okay, Becky and Aileen from Hounslow Community Healthcare, West London Trust, thank you so much for coming onto the programme today and telling us all about your innovations, the community care that you’re giving, the way that your department and your physio services are working towards the three shifts which align perfectly to the 10-year plan so you guys are way ahead of the game and thank you so much for coming on and talking to us today.

Thank you so much. Thank you. Thanks for having us.

That’s it for Advanced Practice Weekly, guys. We’ll see you soon. Take care, everybody, and be safe.