Joining the dots

Busy jobbing clinicians seldom have time to read everything published. Therefore in today’s climate we all need a body of responsible people to highlight matters that need escalating for attention. This article may help. The purpose is not to review the whole document – called First Contact Practitioner (FCP) and the Advanced practitioner (AP) [1] produced by Health Education England (HEE). It contains 117 pages with a large proportion given to tables and forms for assessment. 

I considered the SAKS Report in previous articles, which highlighted the professional body and its strengths, weaknesses, opportunities, and threats. CFP was interested in the idea of First Contact Practitioner (FCP) and the Advanced practitioner (AP), having reported on the Skin Surgery course for Podiatrists in my December 2021 newsfeed. In this article, Will a roadmap to practice reboot podiatry?  – I gather relevant material from several documents. It is essential to be clear that the skin surgery course and FCP are unrelated and not part of any framework. Much thought has gone into the concerns for podiatry attrition, and all podiatrists should make their own decision as to the value of the direction taken chiefly by the podiatry organisations. Health Education England’s goals are “to deliver and reform education to produce the best possible future workforce; to transform the current workforce to meet tomorrow’s health and care needs; and ensure the quality of our education and training system.”

The document looks at the definition, portfolio and how to support training with supervision. HEE primary care training begins at a minimum of five years’ post-registration experience, although the document points to three years for the FCP, which then builds toward A.P. after two stages. Finally, A.P. is completed as part of a third stage if desirable but not mandated.

A First Contact Practitioner is a diagnostic clinician working in primary care at the top of their clinical scope of practise at the Master’s level. (AFC=7, equivalent or above).

An Advanced Practitioner would achieve AFC=8a. Recognition for these grades is through HEE.

The demise of the traditional first contact

Elevating a profession’s scope is something all health care practitioners should aim for. Medicine relegated nail surgery to podiatrists after years of rebalancing responsibilities and skills. As time progressed, the gaps in primary care and that of the traditional first contact, the G.P. medical doctor, has reached a point where medicine is no longer the only method of acquiring assistance for a patient. That gap in medicine has been created because of poor productivity, failed recruitment, early retirement, financial inducements, and the population’s growing needs.

NHS versus Independent Practitioners

Changes are being proposed within the Health Education England document¹ seen at a higher level to fit in with better recruitment. This is not immediately clear from any documents seen as to how this will work smoothly. For the present, most of these changes appear NHS driven. With the greater percentage of podiatrists channelling their efforts into the independent (private) sector, efforts are being made to boost the NHS. Not only is recruitment down for this sector, but the perceived need is increasing, according to NHS employers (2020).

Dr Paul Chadwick for the Royal College of Podiatry (RCP)  acknowledges the efforts behind HEE’s concerns, “There’s a lot of work within Health Education England and HSE [Health Safety Executive] to look at different delivery models of care, which is where first point of contact has come from really because they recognise that G.P.s can’t provide the kind of service that they’d like to because there isn’t enough of them. So that’s the main driver for us.”

One of the problems with focusing purely on the NHS is that the detailed assessment of the independent workforce is less clear. For example, independent podiatry practitioners (IPP) kept working during the pandemic, where some NHS departments were limited. The fact that the I.P.P’s are stretched is well noted but more on social media than in any formal publication. Stratification is poorly mentioned. James Coughtrey [2] suggests it is important to mention that the private sector has not been forgotten in the conversation. Coughtrey focuses on the level of academic robustness between workforce levels. The recent The Podiatrist provides an overview of developing more explicit foot health standards or FHS in its abbreviated form [3]. The driver for change is obstruction of access to services, low recruitment into podiatry courses and a foot health provision that has exploded with confusion. In the background, advisory groups and respondents have been working to find a solution. As Chadwick implies, HEE is come behind an initiative to look at more than just podiatry. Focusing on other Allied Health Professionals, podiatry stands out because of its autonomy which predates the Registration Act of 1960 – the right to act without G.P. reference or direction. The  RCP has produced its paper for members – a condensed form of explanation.

“Employing podiatrists as FCPs would ensure people got the right advice at the right time, and would significantly reduce the workload…” [4] A diagram – Pathway 1 first point of contact (based around G.P. clusters) shows that the idea would entail a patient phoning the G.P. and being triaged and directed to the FCP (podiatrist) in the case of the lower limb. Of course, all patients can access an I.P.P without a referral as no costs accrue to the NHS.

Points of view

Sampling feedback can only be achieved by those prepared to state their views. Many have commented on some of the recent changes, some with less rationality. The following authors make a point that objectively fits the subject matter. In addition, David Holland [5] has his view as an independent practitioner and expert witness.

“I believe the way forward for the U.K. profession is to initiate a new MSc programme which teaches good debridement, practical imaging, 1st-contact prescribing to a high standard, and nail surgery and lower limb and pedal local anaesthetics with an emphasis on plenty of practical (which, no matter what educators say, cannot possibly be taught thoroughly on an undergrad degree course). Some science based around biomechanics would be useful too. In other words the MSc Grad Pod will be a rounded Podiatrist, capable of moving straight into P.P., or able to contribute in a more meaningful way as a stand-alone NHS practitioner. The career-path will develop along the way. In addition the degree will confer academic acknowledgement, currently missing for anyone who wants to train for imaging, prescribing, and advanced local anaesthetics ad-hoc…”

Khatam Khan has been practising for over 20 years as an independent practitioner. (While) podiatry has changed somewhat positively, especially from the medical profession, yet we are still severely restricted in basics such as referrals to hospitals or other lower limb departments/ professionals. This is especially true for private practitioners accessing NHS services for service users. This is something rarely addressed. The lack of engagement with primary care and the position we hold with the skills we have still has yet to be understood and utilised. I find the marketing of what we do by the Society (sic) is very poor, the influence of ensuring we can access services for our users … I find myself in constant turmoil when referring to the NHS, or when trying to reach a collaboration… The recommendations are suffice however many fear for the use of the protected title, how this will impact patient care, private practitioners and deskilling of the workforce within the NHS.[6]

The Roadmap to Practice as a document  [HEE roadmap]

The document states, “the FCP Podiatrist is not expected to make a diagnosis but rather keep an open mind and treat according to presentation, formulating an impression/differential diagnosis as to what might be the cause and what needs escalation to be ruled out.” P.18

The Royal College of Podiatry document [5] is more accessible, but offers basic details. For the educationalists and managers, detail in the HEE document makes a case for skills development. Although there are others behind the scenes, Helen Beaumont-Waters and Dr Lindsey Cherry stand out behind the document [7]. Four other groups are mentioned alongside the designated skills accrued to form a FCP or Advanced Practitioner as an AHP. Paramedics, MSK, dieticians and occupational therapists. For the most part, this document is about the process rather than the arguments around the justification for change. We see that five distinct designations are emerging from recent papers and development covering foot health services [8]

• FCA (foot care assistants)
• FHP (foot health practitioners)
• AP (assistant practitioners)
• FCP (first contact practitioners)
• AP (advanced practitioners)

The four branches or pillars are associated with an expansion of skills and standards  and relate to knowledge, skills and attributes (KSA):

• knowledge & understanding
• analysis & argument
• reading & research
• communication & presentation.

The ideas behind training are aimed at the Master’s level, where scores are made against the four pillars of practice. Evidence is mapped against the KSA within the domains. Each domain has subsections where skills are to be achieved. Clinical supervisor forms are shown to assess achievement and make up a sizable proportion of the document. The document¹ considers the training process as four domains – A-D; this example is one of the capabilities of which there are a wide variety of objectives to meet for both the FCP and A.P.

Domain C: condition management, interventions, and prevention
Demonstrate comprehensive, advanced knowledge of prognostic, risk, and predictive factors of relevant health problems in relation to all podiatric management strategies e.g. adequate vitamin D for bone health, and the effects of smoking, obesity, mental health, frailty, inactivity etc.

What does this mean for the podiatrist?

Being a Foot Care Practitioner brings the podiatrist into line with HEE standards expected to deliver a service as a rounded clinician rather than specialist. Could we hear podiatric physician as a title? The following areas include managing:

• Management of the high risk foot
• Diagnosis of new lower limb problems
• Support of people living with long term conditions
• Maintaining physical activity and wellbeing

The RCP³ document runs to 11 pages; while helpful, this only tells part of the story. Taken with Smethurst’s article, the reader can see  benefits; the devil might be in the detail or not! The General Medical Services contracts allow healthcare professionals to work alongside G.P.s through a reimbursement scheme, so this implies that anyone who can achieve the appropriate training and meet the standards prescribed by HEE can be gainfully accredited and employed (P.3⁴). Beverley Harden [9] suggests that “I would love private practitioners to think about the primary care first contact practitioner opportunities and return to the NHS for several hours a week on an NHS contract.”

It seems that moving into a band 7 on a part-time basis might not be attractive to a successful podiatrist in the independent sector. Has Harden examined why podiatrists leave the NHS? Part-time only appeals when you need more financial support or objectively like mixed practice variation. Podiatrists leave university with many skills embroidered into the domains and skills framework. Someone is making it clear that the University programmes are not meeting all the framework expected of a podiatrist. Being a cynic, there is a duality to this qualification as that is what this is. Upskilling means taking on the role of the G.P. in many cases specific to the lower limb. There is a saving in funding such a post compared to a G.P. The idea is to improve patient flow. Who could argue against this?  

The idea of three years to gain experience seems unclear when supervisory support would be better after the first degree during the novice years. The RCP document (P.9⁴) suggests “the benefit to the patient of the FCP model should be rapid access to the right person, at the right time, in the right place…” If the workforce is not available, this will be difficult despite an excellent aspiration. One wonders if this imposed time delay to start training is not counterproductive. Looking at some of the debacle of vaccinators and the difficulties imposed on some skilled professionals, additional bureaucracy can hamper aspirations.

If the greater proportion of F.C.Ps are placed in the NHS, squaring this circle will be challenging as recruitment needs to be fixed first, even though the idea behind some of these projects involves improving recruitment. For example, a band 6 podiatrist could make band 7 faster than waiting to go through yet another process. Of course as competitive numbers grow, this option will reduce. Band 5, the starting point for AHPs, is difficult to assign presently with so many shortages in the workforce.  In the 70s, we all started on Whitley contracts with senior II bands rather than the Basic grade. This in-built problems has not  changed in over half a century!

On a positive note, the value behind HEE-backed posts comes with assured training objectives. A post-graduate podiatrist might be attracted to a staged process with the potential for a salary commensurate with a band 7 or higher if this was not achievable locally. Long term, the value of meeting the aims and assigned goals will reinforce the original BSc podiatry qualification. Podiatric surgeons (PS) already suffer from an extended course of study post-graduation of 7-8 years. Obtaining supervision places, funding and sufficient case-loads to build portfolios have not been uniform in podiatric surgery. However, HEE has already made many roads to improve the P.S. training, so one might be assured that their aim and success will be united.

Final word

Young podiatrists today look for scope expansion and in truth, much of this is about diagnosis, triage and referral. Extended scope practitioners already have achieved a broad medium of progress in the NHS and clarification needs to be amplified. For example, the documents have no apparent link to podiatric surgery [10] triage by the Integrated Clinical Assessment-Treatment Services (ICATS). Time will be the judge of success, no doubt. However, Universities attracting student podiatrists will have to look carefully at these developments and the process of education and skills. Providing the tools and balance for delivering a service falls to these institutions to ensure they provide the right skills. Holland can have the last word – “The nettle – that perhaps our new podiatry graduates are not as well-trained as we would like – will have to be grasped firmly. Note that this will only work if the will is present amongst educators to concentrate on the finished product – a well-rounded Podiatrist.”

Useful references used in preparing this article
Abbott, A, Wylie, DA. Value Chain Analysis of U.K. Foot Health Service Provision. 1996-2020. 25 September 2020.
NHS England. Allied Health Professions into Action. Using Allied Health Professionals to transform health, care and wellbeing. 2016/17 – 2020/21 Jan. 2017

• [1] Health Education England. First Contact Practitioners & Advanced Practitioners in Primary Care (Podiatry) September 2021
• [2] James Coughtrey is Head of Education and Professional Development at the Royal College of Podiatry. Cited in Smethurst’s article (3).
• [3] Smethurst, S. Rebooting the Profession. The Podiatrist. 2021;November:10-12
• [4] The (Royal) College of Podiatry. Podiatrists as First Contact Practitioners. 2021
• [5] David Holland 20/12/21 open access correspondence published on ConsultingFootPain.
• [6] Khatam Khan 9/12/21 open access correspondence published on ConsultingFootPain.
• [7] Contribution to the Podiatry Knowledge Skills and Attributes was led by Helen Beaumont-Waters, advanced practitioner (paramedic/podiatrist, Kensington Partnership) and Dr Lindsey Cherry, senior clinical academic podiatrist (University of Southampton & Solent NHS Trust). Supervision content was led Julia Taylor (Lister House Surgery and Health Education England). The (Royal) College of Podiatry, along with respective specialist interest groups and the Institute of Chiropodists and Podiatrists.
• [8] Health Education England. A Standards for Foot Health Workforce was published in August 2021
• [9] Beverley Harden is Allied Health Professions lead at Health Education England
• [10] Podiatric surgery as a specialty is covered by the Royal College’s own documentation and reference to MSK covers the format of ICATS and remains the only formalised advanced scope for podiatrists with its own annotation and specific degree.

Thanks for reading Will a Roadmap to Practice Reboot Podiatry? written by David R Tollafield 

Published by Busypencilcase Communications Est. 2015 for Consultingfootpain

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