For ease of reading and in keeping with the methodological principles outlined above17 we combine the results and discussion sections to enable presentation of emerging findings, theories, and interpretations in context.
The online survey was completed by 21 students and six clinical mentors, the cohort included 56 students and 47 clinical mentors (some mentored more than one student) (see Table 1).
Table 1
Characteristics of online survey respondents and interview participants.
ONLINE SURVEY | Participants (n = 27) |
Students | |
Profession, n | |
Dietitian | 2 |
Paramedic | 9 |
Physiotherapist | 10 |
Clinical experience (yr), mean (range) | |
Dietitian | 10 (9–11) |
Paramedic | 15 (7–23) |
Physiotherapist | 18 (8–30) |
Clinical mentors | |
Profession, n | |
Dietitian | 1 |
General practitioner | 1 |
Nurse | 2 |
Physiotherapist | 2 |
INTERVIEWS | PARTICIPANTS (N = 8) |
Students, n | |
Dietitian | 1 |
Paramedic | 3 |
Physiotherapist | 2 |
Clinical experience (yr), mean (range) | |
Dietitian | 10 |
Paramedic | 14 (6–22) |
Physiotherapist | 21 (17–25) |
Clinical mentors, n | |
Dietitian | 1 |
Physiotherapist | 1 |
We created two categories informed by the total empirical material, including quantitative and qualitative data; 1) The perception of the utility of the module is influenced by personal circumstances, professional identity, and mentoring experience, and 2) Profession-specific competence not concordant with capabilities required for primary care gatekeeper role.
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The perception of the utility of the module is influenced by personal circumstances, professional identity, and mentoring experience
Preparing for the FCP role
Our survey and interview data indicate that both students and clinical mentors thought the implementation of the FCP role has added value to primary care, but that is also has created some challenges at the point of delivery. Survey data show that most students and clinical mentors agreed with statements about how the module has been useful in preparing students for the FCP role, through making them safer, more effective, more confident dealing with uncertainty, better at safety-netting, and taking on more responsibilities (Fig. 1). The majority of survey participants indicated that having a FCP as part of the primary care workforce improves patient care, all students agreed with this, whilst of the clinical mentors, one (a nurse) was neutral and one (a physiotherapist) mostly disagreed (Fig. 2). When exploring the qualitative data a more nuanced picture emerges. A student viewed the utility of the module through a prism of their own professional grounding:
I totally understand that the module is more about a building block into primary care, learning how primary care works as a whole, how we implement changes into primary care, and how the consultation models that are used by GPs in primary care are totally different to the stuff that we use prehospitally. (FCP student, paramedic)
A clinical mentor highlighted the different challenge for dietitians:
It’s hard for dietitians as it is an emerging area of practice. They have knowledge gaps that other clinicians may not have (e.g. clinical examination skills). As such, the module in isolation is not likely enough to allow them to fully take on a FCP role. This is not a reflection of the module, more of where the profession is and where it needs to be. (Clinical mentor, dietitian)
One student embarked on the module as a way of progressing her career and seeking a new challenge:
I've been in emergency care for 25 years and I was just feeling a little bit stale. I've been quite involved with the 111 urgent care providers through the ambulance service, and I just felt that I needed a new challenge. (FCP student, paramedic)
Another student viewed the FCP role as a step towards gaining advanced clinical practice qualification:
It's fantastic, this notion of first contact practice and being able to advance your skill set. But equally if that opens up the doors to ACP [Advanced Clinical Practice], that’s raised the ceiling from where we've been. (FCP student, dietitian)
But for another student the module was a condition for her being able to continue in the role she had already started:
The fact that I changed role, and (…) the compulsory thing was to do the module. That was the only reason I did the module because it was part of my role, it was expected, and it was something I had to do to stay in my role. (FCP student, paramedic)
One student reflected on the importance of implementation at the local level and how this determines the utility of the FCP role:
I think me moving [Primary Care Network] has [altered my view of the FCP role] as this highlighted the impact of how the management and organisation of the FCP in practice can make this role effective and enjoyable or ineffective and stressful. (FCP student, physiotherapist)
A clinical mentor thought that the FCP role might be easier to implement in more established practices:
I think mainly it depends on how mature the primary care environment is that they are moving in to. If the PCN [Primary Care Network] is well developed then I think the role will work better than where the PCN is in the early stages of development (Clinical mentor, dietitian)
The FCP role is a career progression opportunity that can satisfy personal ambition, but also represents a way to improve street-level bureaucrats’ performance through professional development. New FCPs must navigate different local organisational dynamics, and Lipsky18 questions whether professional development is an approach that increase responsiveness to clients, based on the record of the professions. Next, we look at how the mentoring aspect impacts the FCP journey.
The importance of clinical mentorship
The clinical mentor role was seen as worthwhile by the majority of the survey participants, 19 students and five clinical mentors agreed with this, only one clinical mentor (a physiotherapist) disagreed. However, the expectations of the clinical mentorship varied. A student was initially confused by the module requirement to develop individual learning objectives to be met in clinical practice:
As paramedics we are used to very clinical courses ¨This is what you need to learn¨, and all of a sudden I've got to make my own list of things that I need to learn. That baffled me a little bit, but I got it. (FCP student, paramedic)
The GP who completed the survey mostly disagreed that mentoring had been a worthwhile undertaking, suggested less emphasis on transactional learning and instead more application of learning to the ¨real world¨ was needed, and was critical of the clinical mentor role:
This was not a mentoring experience I recognised from my role as an experienced mentor to postgraduate doctors. The student expectations of the role and my expectations were not aligned (Clinical mentor, GP)
The varied accounts from students about their experiences around the mentoring process tell a story of a varied landscape for the nascent FCP to navigate:
I know some people have had quite a few issues with their mentors, you know, stating ¨I've got no time¨. (FCP student, paramedic)
My clinical mentor was a gem; however, my awareness was that his pressures were high. Training other students (doctor trainings) takes priority and has protected time (FCP student, dietitian)
I gained a lot of reassurance and greater understanding of the First Contact role working with the clinical mentor, despite the limited time available. (FCP student, physiotherapist)
Mentorship is highlighted as a core need for staff in FCP roles20 and our participants stressed the importance of the clinical mentor role. Lipsky18 describes a process where professional recruits are socialised to the dominant professional values, and this makes clinical mentoring by a GP perhaps particularly important for FCPs who move into the primary care setting traditionally dominated by the medical profession. It is therefore important that steps are taken to address the ambiguity found among some GPs about the impact of multidisciplinary working on them and their working practices.20
From implementation to utility
The reflections on personal circumstances, professional identity, and mentoring sit in the context of the FCP role becoming part of a changing primary care landscape that affects professional boundaries, shifting AHPs from their traditional roles into unfamiliar territory. Nancarrow and Borthwick21 argue that whilst the allied health professions have become necessary to meeting the demand for a flexible workforce, these professions have increasingly become a commodity to plug gaps in the interest of the state and the healthcare system. Lipsky18 outlined the measures typically taken by the state to influence the direction of professionalisation; higher salaries, improving and subsidising training, making advancement dependent upon meeting professional standards of performance. Further, Lipsky18 proposed that the success of reforms, such as FCP roles financed through ARRS, depend upon the alignment of the new model with the core values of the stakeholders, the clarity of the mission, and the extent to which the street-level bureaucrat can improve their performance in pursuit of the mission. This raises the question whether adequate foundations and building blocks have been provided by policymakers for the FCP model of care to be implementable.
Our survey and interview participants indicated that a clear definition of the FCP role is missing, which might sit in contrast to the perception by policymakers that there is a clear blueprint for the implementation of the role. The policy of workforce transformation seems to be challenged by shifting sands in the landscape that the FCP and their employers have to navigate. The FCP role must necessarily develop based on the local context,20 but the apparent variance in implementation suggest that policies and roadmaps do not accurately describe the terrain yet. The King’s Fund20 reported that it is not universally understood how additional roles, including the FCP role, might contribute to general practice, despite the plethora of written guidance, job descriptions, and roadmaps, which may even have contributed to the confusion. Consequently, FCPs and their employers are put in a situation where they to some extent need to find their own path, and this exemplifies how the discretion, decision-making, and interpretations of healthcare professionals impact the implementation of healthcare policies and initiatives.
2. Profession-specific competence not concordant with capabilities required for primary care gatekeeper role
The transition to the FCP role
The FCP students were experienced clinicians who all had from six to 30 years of clinical experience (see Table 1) yet some felt they fell short of the requirements of working as a FCP in primary care. Eleven of the 21 students (six physiotherapists, four paramedics, one dietitian) completing the survey agreed that they still felt they had shortcomings in relation to the FCP role, and two clinical mentors (a GP and a dietitian) agreed that students had these shortcomings (Fig. 2). A paramedic student and a dietetic clinical mentor highlighted the differences between previous roles and the FCP role:
The majority have come from an emergency background, which is obviously acute presentations, being with the patient for a very, very short period of time, dropping them off at a hospital or leave them at home with self-care management. To actually start to do a full holistic approach, start to finish, thinking about other things during the consultation like the social prescribing aspects and things like that. At the beginning of the course, I didn't really know the full range of what an FCP paramedic would do, the full scope. (FCP student, paramedic)
Dietitians don't really do any clinical examination, but they need to be able to do it for first contact. (…) Understanding primary care and understanding that it is completely different, and that you're not aspiring to deliver your community service in a GP practice. So, getting their heads around that, that it is completely different, that you can't discharge patients, safety netting, you know. I think because dietitians who come into these roles are already really experienced, they've got 10 years of working maybe in a community setting, it's a different mindset working in primary care. (Clinical mentor, dietitian)
The transition from the typical AHP role to that of an FCP, where patients have direct access through self-referral or reception triage, comes with new challenges. FCPs frequently describe an elevated level of clinical complexity and diagnostic uncertainty that is outside of their usual scope of practice, combined with a pace of work they are not accustomed to.22,23 As seen in Fig. 1, the survey participants tended to agree that the module has helped students develop their confidence in dealing with uncertainty, and managing uncertainty was mentioned by two students (physiotherapists) as one of the best features of the module. A clinical mentor (dietitian) described the feelings of her FCP student when having to deal with uncertainty and risk as ¨Terrified¨. A student gave an account of the different level of complexity in primary care compared to her emergency care role:
For me, the uncertainty was about the complete picture, knowing what to ask for when the results come back. What does that actually mean. Knowing what medications are given for what. When you do give antibiotics, when you don't give antibiotics. That was the thing that I wasn't sure of, which is the difference between primary care and emergency care. (FCP student, paramedic)
A physiotherapist expressed that he was now more comfortable with uncertainty:
As I've become more experienced in the role, I've realised it's OK to be uncertain. I think when I first started, I was trying to solve everybody's problems and I realise that's not possible. (FCP student, physiotherapist)
Central to the provision of safe and effective care at the first point of contact is assurance of competency, capability, and training.23 The empirical material suggests a narrative where an initial expectation of developing competence to an extent develops into an understanding of the need to develop capability. In the complex world of primary care it is critical to develop capability, that is, practitioners being able to adapt to change, to generate new knowledge, and to continuously improve performance, rather than focusing on enhancing competence (knowledge, skills, and attitudes).24 There might be legitimate questions to be explored around possible reasons for the apparent capability gap between experienced AHPs and the expectations of FCPs, such as content of pre-registration curricula and opportunities for post-graduation professional development. Undertaking the module might constitute one of few opportunities for AHPs to secure time and financial support for continuous professional development.
Multidisciplinary teamworking
The empirical material suggested that students valued the multidisciplinary aspect, but more in hindsight than during the module. Students pointed towards the virtues of multidisciplinary teamworking and the corollary benefit of freeing up time for GPs to manage complex patients, but also highlighted the logistics of role implementation as a problem:
The FCP role works very well in primary care, the holistic approach to patient care with a multidisciplinary team available at the front door gives a complete package of care and enables GPs to deal with the more complex patient groups. (FCP student, paramedic)
I think it is a very good role, however, the effectiveness depends very much on the organisation and management in the individual practices. There is too much variation and FCPs can be spread too thinly over too many GP practices to be effective. I also think there is generally very little understanding of the role at present. (FCP student, physiotherapist)
A clinical mentor lamented what he saw as lack of understanding of the FCP role amongst primary care colleagues:
Fundamentally, they have absolutely no idea what's going on. And I'm talking about the GPs, nurse practitioners, pharmacists, the admin staff, there is no understanding of what FCP is, despite the fact that we've done a lot of work trying to present to the PCN [Primary Care Network] […] a lot of work embedding our service, our team into their team. (Clinical mentor, physiotherapist)
This suggested lack of clarity about the FCP role and its scope might present a challenge to teamworking in primary care, and cause confusion around decision-making authority and accountability. A student explained how she had been assigned the job of completing reviews of patients with learning disabilities as part of her FCP role:
We’d missed the targets basically, for the previous three years for the LD [Learning Disabilities] reviews, and my clinical lead and all their practices wanted to hit the benchmark for the DES [the Network Contract Direct Enhanced Service]. So, there was a lot of pressure for me to box that off and I was the only clinician doing them. (FCP student, paramedic)
Systems thinking on health policy in the United Kingdom has highlighted the importance of framing policy that enable front line workers, rather than seeking to control them.25 The extent to which this has been achieved with the implementation of the FCP roles is debatable. Lipsky18 outlines the development of new and sharpened tools of government that seek to shape the future of street-level bureaucrats, through the production of public policies where subsidies, public-private partnerships, and contracting for services are key features. These policies are recognisable in the Network Contract Direct Enhanced Service26 that came into effect in July 2019 and sets out the principle of additionality, which includes the central aspect of workforce expansion to enhance the skill-mix and capacity of the primary care workforce. Further, the contract outlines the minimum role requirements for the ARRS funded roles, and it is apparent that the task the FCP student above was asked to do (Learning Disabilities reviews) sits outside of these requirements.
In their report about the integration of additional roles into primary care networks, Baird et al20 found ambiguity among some GPs about what multidisciplinary working means, both clinically and in the running of their practice. This points to a lack of consideration - on the part of policymakers - of how the GP role and the organisation of general practice might need to change, to align with the vision of multidisciplinary working in general practice. The introduction of the FCP role constitutes a cultural change and necessitates new approaches to teamworking, but the organisational development, leadership, and service redesign expertise required has not been adequately available to Primary Care Networks.20 Reported barriers to inter-professional collaboration in primary care include lack of long-term funding and lack of leadership at the organisational level,27 and more active support from funders is required to change the organisation around implementing new roles within general practice.20
The allied health professions are a necessary part of the workforce to deliver the primary care services required by the state.21 At the same time as competing for space in the domain of emerging roles, AHPs defend historical boundaries within a context of needing to conform to political and economic solutions to healthcare workforce shortages.21 There is evidence to suggest that a key lever for multidisciplinary teamworking in primary care is to get professionals to work together and learn from each other in practice.28 Further, it is plausible that the exercising of discretion by healthcare professionals in their meetings with patients, central to Lipsky’s theories on street-level bureaucracy, can influence the dynamics of teamwork and collaboration, and the development of collaborative relationships between professionals in primary care typically evolve on a case-by-case basis and rely on personal knowledge and trust.29 It might therefore be useful for those involved with implementing the FCP role to consider how to facilitate the development of effective and sustainable multidisciplinary teamworking, whilst taking into consideration the different scopes of different professions as well as the local needs and expertise, to foster positive collaboration in order to enhance patient outcomes.
Limitations
We only managed to recruit one GP to take part in the online survey, none of the 47 clinical mentor GPs were willing to take part in an interview. There are several possible explanations for this lack of engagement, including lack of time or interest in the topic, as well as inadequate funding to provide GPs with the necessary support to be able to offer clinical supervision and managerial support. However, it is also conceivable that the non-participation from GPs could embody an act of passive resistance,30 as a manifestation of resistance to the creation of interprofessional teams that might threaten established systems of professional power, hegemony, and prestige. But it might also reflect the significant pressures GPs face in primary care, where seeing patients must be prioritised ahead of research participation.
A strength of our study is the ongoing process of reflexive self-awareness that emerged as an integral component of our inquiry. We recognised that both conducting and listening to the interviews, and reading the interview transcripts, had an impact on our experiential perspectives. We focused on the interaction between discovery and comprehension, aiming to understand the participants’ perspectives and to interpret and make sense of our own contributions to the interviews. Based on our methodological approach we did not search for any objective meaning to be discovered, but to co-create meaning with participants and the empirical material.31