Introduction
The concept of having musculoskeletal (MSK) expert physiotherapists sitting as the first point of contact for patients in primary care was initially established in mid 2010. By 2016, national trials were being funded and accessed through clinical commissioning groups (CCG’s).
Pure Unity Health was part of the early national trials specifically looking at reducing pressure on general practice in terms of the musculoskeletal workload, as well as supporting onward pathways into community and secondary care. When these trials were concluded, the results fed into the development of the Additional Roles Reimbursement Scheme (ARRS) which was launched in 2019.
In 2020, increasing numbers of physiotherapists moved into the role of First Contact MSK Practitioners (FCP). This formed a major part of the new clinical roles in the NHS 5-year plan, which introduced diverse clinical and non-clinical roles into primary care. The 5-year plan concluded in 2024, but due to the political change it was rolled forward for one year concluding at the end of March 2025. With the incoming Labour government, there has been a recommitment to the ARRS, expanding its scope to include newly qualified doctors and nurses. Additionally, the funding available for roles such as FCPs and other primary care positions has been increased in line with the wider NHS Agenda for Change (AfC) structure.
The integration of additional roles into primary care over the last six years has, overall, been a very positive experience. Although time to embed the roles and get the maximum from them has been put under pressure, not least by COVID-19 interrupting a large part of that process with worldwide disruption and massive challenge to the NHS as we tackled with the national health crisis. Over the last few years, there have been several research studies concluded and published identifying and reviewing the impact of MSK FCP roles in general practice.
In this blog, I aim to explore the impact, cost-effectiveness, and patient benefits of First Contact Practitioners (FCPs) in primary care. I will cover:
- The growing demand for MSK care and the rise in long-term MSK conditions.
- A comparison of employment models for FCPs—direct employment vs. outsourcing.
- The financial and clinical benefits for both primary care and patients.
- Future prospects for MSK FCPs amid increasing demand and an evolving primary care landscape.
Increasing pressures of long-term conditions on the NHS
The government has identified several areas of long-term conditions which are increasingly leading to poor health outcomes and increased spending. Ranging from mental health, metabolic disorders, obesity, all the way through to musculoskeletal chronic pain.
Demographic data shows that up to 30% of primary care consultations are linked to a musculoskeletal disorder, and MSK problems are one of the leading areas of increasing chronicity in the Western world. Management of spinal disorders and low back pain as well as osteoarthritic issues affecting hips, knees, and other joints have a huge impact on individuals’ lives and their ability to be functionally and economically active.
Physiotherapy has been well established as a clinically and cost effective way to manage musculoskeletal problems and minimise the functional impact it has on individuals and society. Introducing specialised First Contact Physiotherapists into primary care helps ease the burden on primary care teams while improving patient outcomes. This approach also reduces costs for the broader healthcare system by decreasing the need for imaging, limiting referrals to secondary care, and increasing the efficiency of surgical interventions for patients who do require specialist treatment.
UK government research states that arthritis and musculoskeletal conditions affect over 17 million people across the UK, causing pain, disability, fatigue and often anxiety, depression or social isolation.
Pain and joint stiffness limit movement, making activities such as spending time with family and friends or looking after a household much harder. Over half of people (57%) living with arthritis say they experience pain every day. These conditions disproportionately affect those who are socially and economically disadvantaged. The impact of arthritis also stretches beyond the individual to services and the economy.
Each year, 20% of the population consult their GP about an MSK problem; and MSK conditions account for the third largest NHS programme budget.
Beyond the health service, MSK conditions are also responsible for 23.4 million working days lost each year, having a substantial impact on the economy.
Below are some really great graphics taken from the Versus Arthritis website. Click here to view their website and learn more.
Contrasting employment structures for FCPs: directly employed vs outsourced
Pure has been providing FCPs to primary care since 2016 in the early NHS England trials. When PCNs were created in 2019, we were already working with around 90 practices providing FCPs via their core practice budgets. Fast forward to where we are now, and we help to support over 240 primary care networks with expert FCP services focused on local practice and PCN need. However, there are also options for employing FCP through direct employment rather than via a specialist FCP or community provider.
Over the last few years, we have talked to numerous primary care networks who have directly employed, looking to directly employ, or who have been in discussions about moving their provision from direct employment to a supported service of FCPs.
Both options can work if the appropriate level of support, governance, and clinical development is put in place. One of the main challenges of direct employment is the ability of the PCN staff to provide full regular peer support from other First Contact Practitioners, as well as clinical and continued professional development support from accredited supervisors in primary care such as GPs.
NHS stipulates a split between clinical and non-clinical time for all the FCP roles of 80% clinical and 20% non-clinical, recognising the need for non-clinical elements of peer support, clinical debriefs, audit and quality improvement projects as well as data collection and presentation. This should ultimately result in service improvements that are demonstrable and directly linked to patient feedback, as outlined in the road map to practice governance documents. This is required by all FCPs working in England drawing down ARRS funding.
When considering direct employment, it’s worth recognising that whilst the non-clinical time for the practitioner is important, allowing supervision time from an appropriately qualified clinical supervisor during that non-clinical time is also needed. Sometimes this is difficult to make work when GPs who would typically do this type of supervision have to block out clinical time to supervise the FCPs in practice.
Many PCNs transition from direct employment to a supported service because it offers cost savings and enhanced support for FCPs in practices. However, direct employment can still be a viable option if both the practice and the PCN are committed to providing regular training and allocating appropriate non-clinical time (20%).
The challenge lies in balancing time and cost while ensuring maximum appointment availability for patients and maintaining cost-effectiveness within the ARRS structure.
Cost and clinical benefit to primary care networks and patients of MSK FCP support.
In the past few years there have been several reviews of the clinical and cost benefits of MSK focused, FCP-led primary care services. A publication by Walsh et al in the British general practice, October 2024 specifically reviewed the cost savings to the health system as well as primary care and the clinical benefits to patients. Her team concluded that not only were patients with musculoskeletal problems treated quicker and started their recovery journey in a more effective manner, but also there were significant reductions in prescriptions.
NICE guidelines and other evidence support the view that painkillers and anti-inflammatory should be prescribed only as a last resort with musculoskeletal problems. The knock-on side effects from anti-inflammatory and high strength painkillers are well publicised in terms of the negative impacts on the gastrointestinal system, dependency, and addiction issues.
Since most musculoskeletal disorders are relatively self-limiting with proper advice and guidance, involving specialist musculoskeletal practitioners early in a patient’s care can significantly improve initial management and help reduce the risk of these conditions becoming chronic or prolonged.
What the future might hold for the role First Contact MSK Practitioners
Given the government’s continued commitment to expanding primary care roles and supporting a diverse clinical workforce, it is highly likely that the First Contact Musculoskeletal Practitioner role will remain a permanent fixture.
Recognising the cost savings and additional clinical benefits patients received identified through research gives us a positive outlook for the increasing benefits FCPs can give to primary care.
Recent increased flexibility within the ARRS opens up far better flexibility for primary care networks to decide how they utilise the funding, and whilst this could be a challenge for some of the additional roles that have been utilised within primary care, the First Contact roles, given the clinical and cost benefits to practices, are likely to remain and increase as a mainstay of general practice. However, it is also important to review the outcomes of First Contact services to ensure they provide the greatest benefit to both patients and practices.
Ensuring that the appropriate level of clinical governance, peer support, and stability within the clinical teams around training and development is essential. Furthermore, transparent and accurate data collection and analysis to allow meaningful service development is also key.
If you have an FCP service working within your PCN but you are unable to gain easy access to activity, outcome data, and patient feedback, we strongly encourage you to push to get this information. Only with this can you implement meaningful change to improve services across primary care.
Pure was fortunate enough to be shortlisted for the 2025 HSJ Partnership Awards due to the high-quality data we provide monthly to the primary care networks we collaborate with. We have used this data to enhance staff training and improve the services delivered to patients. With a small investment in time and effort, the benefits of integrating relevant data into service improvement are enormous.
With the increasing demands on primary care from an ageing population and increasing long term conditions around musculoskeletal health, it is important that First Contact roles provide the maximum impact for both patients and practices, both clinically and financially. The knock-on benefit to the wider health system and society is significant and, as further research is published over the next few years, it’s likely we will see this benefit more easily demonstrated.
Integrating the primary care workforce, including GPs, nurses, First Contact roles like physios and paramedics, along with social prescribers, pharmacists, and other key professionals, is likely the most effective way to run modern general practice. By no means am I saying this is an easy thing to achieve, but I do feel that with supported clinicians working towards a common goal for patient benefit, the future is very bright for First Contact Practitioners working in Primary Care as part of their integrated neighbourhood team.
If you’d like information about our supported primary care services we provide such as persistent pain support, health and well-being coaching and social prescribing, long-term condition management, and women’s health. Feel free to reach out at fcp@purephysiotherapy.co.uk —I’d be happy to discuss it with you.
Find out more about First Contact Physiotherapy
Phin Robinson BSc (Hons), MSc Advancing physiotherapy, PG Dip Orthopaedic Medicine.
After qualifying in 2001 Phin has worked as an MSK physiotherapist within the NHS and independent sector. He has been an injecting therapist since 2006 and spent 15 years working as an advanced practitioner in MSK between primary and secondary care settings. He heads up Pure Unity Health Group and remains passionate about the physiotherapy profession and the positive impacts that can be gained from quality physio led MSK care. Since 2020 Phin has taught on NHSE accredited FCP courses and works part time in an FCP and ARRS ambassador role.
