Developing programme theories to understand 'First Contact Physiotherapy' in Primary Care: A rapid realist review (FRONTIER)


First Contact Physiotherapy (FCP) is a new primary healthcare model in which a specialist physiotherapist in Musculoskeletal Disorders (MSKDs) located within general practice, undertakes the first patient assessment, diagnosis and management without the requirement for prior GP consultation. It is intended to provide additional capacity and diversify the primary care workforce to meet the high demand for MSKD appointments and the challenges of recruiting and retaining GP staff. Initial audits of the service propose the FCP model may free up GP appointments, reduce secondary care referrals and scan requests, improve patient satisfaction, and produce cost savings. However, there is a lack of robust research evidence, and limited understanding of how best to implement FCP given contextual variation in general practices across the UK. This rapid realist synthesis generated and refined programme theories to develop insight into “What it is about FCP in Primary Care that works, for whom, in what circumstances, how and why?”. This was the second stage of a four-part project exploring the FCP role.


Preliminary programme theories proposing causal relationships exploring key mechanisms of the FCP role were developed iteratively, through scoping the literature and consultation with expert stakeholders. Following this a formal literature search of 7 published databases (AMED, CINAHL, Medline, SPORTDiscus, PsychInfo, Embase and Cochrane) identified 7511 records. Searches of the grey literature identified 12 videos and additional website, blog and social media sources. A team of 6 authors are in the process of screening and extracting data, analysis will be managed using Excel. The findings will be synthesised and further refined through a consensus exercise with a focus group of key stakeholders. Following this a finalised set of Programme theories will be developed to inform understanding of FCP and the next primary research phase of the FRONTIER project.


Preliminary programme theories guiding the Realist review explore the FCP role in terms of:

  • Communication (including multidisciplinary working, perceptions and understanding of FCP)
  • Patient management (including assessment, diagnosis, treatment and patient safety)
  • Patient pathways through primary care (including referral processes and effects on staff workload)
  • Efficiencies in healthcare resource usage and workforce

Following data extraction additional theories associated with “How FCP works, for whom, in what circumstances and why” will be developed. Results will be available by September 2019.

The programme theories developed from this realist review will provide insight into the mechanisms which allow FCP to achieve its intended outcomes and aid understanding of any unintended consequences. These insights will form the basis for interviews with primary care professionals and patients to fully evaluate the FCP role.


The programme theories, alongside the wider FRONTIER evaluation of FCP, will provide insight into how contextual variation of the implementation of FCP affects delivery of the service. This will be of use to inform decisions around physiotherapy staffing, delivery and primary care funding.

Funding acknowledgements

NIHR HS&DR (16/116/03)

Additional notes

This work was presented at Physiotherapy UK 2019