Study Protocol: Exploring complexity of First Contact Physiotherapist caseload and experiences of dealing with uncertainty in primary care in N.Ireland.

Background: During the last 30 years Northern Ireland has experienced a series of social and economic problems which are either directly or indirectly associated with a period of prolonged violence and civil unrest known as “The troubles”. These problems include severe deprivation, long-term unemployment, economic inactivity and a legacy of poor mental and physical health. Since 2014, the number of GP practices in Northern Ireland has declined by 8% (Department of Health, 2021). FCPPs were introduced in Northern Ireland to ameliorate the pressures in general practice and fulfil the aspirations set out in ‘Health and Wellbeing: Delivering Together 2026 (DOH 2017). Despite evidence highlighting the contribution of FCPP to the primary care setting, research suggests the transition from department based secondary care setting to first contact primary care settings has not been without challenges . Introduction: FCPPs were introduced in Northern Ireland to ameliorate the mounting pressures in general practice and to fulfil the aspirations set out in ‘Health and Wellbeing: Delivering Together 2026 (DOH 2017). Although these roles bring opportunities for the FCPP to be at the forefront of influencing patient access to quality services, they also bring substantial challenges associated with working with clinical complexity and uncertainty in primary care. This phenomenon of clinical complexity and uncertainty in management of MSK conditions and its relationship to various health and healthcare-related outcomes has become the focus of an expanding body of empirical research within the medical profession in GP settings (Alam et al., 2017). As pointed out by Greenhalgh et al., 2020; Langridge 2019; Moffat et al. 2018; Maharaj et al. 2018, Yelman, 2021) there is a lack of research investigating the experiences, impact and training of FCPP in management of clinical risk and diagnostic uncertainty. This suggests that the phenomenon of clinical complexity and uncertainty in FCPP management of musculoskeletal conditions is not fully understood and warrants further research into this area. Primary research aims: To explore the clinical complexity of FCPP case load in primary care settings in Northern Ireland. Secondary aims: To explore the experiences of managing clinical complexity from the perspectives of FCPP in Northern Ireland To explore how FCPP epistemological may influences their affective and behavioural reactions to uncertainty. To explore diagnostic referral rates are influenced by the level of clinical uncertainty experienced by clinicians in dealing with patients musculoskeletal disorders Proposed Methods: A pragmatic mixed methods exploratory convergent-parallel design will be utilized involving primary data sources. Data will be collected using a mix of semi structured interviews and descriptive and analytical surveys with validated measures across 7 GP Federations in Northern Ireland with fully implemented FCPP services. This may limit generalisability to the wider UK situation however the transparent description of participants and setting enables readers to access transferability to the readers local context. Conclusion: This research will aim to help inform debate regarding to sustainable model of workforce provision with a robust financial, education and support model to meet the needs of the both the clinicians and patients in primary care settings.