Understanding the retention and support needs of UK first contact practitioner physiotherapists in primary care; a realist review

First Contact Practitioner Physiotherapists (FCPPs) have been widely implemented in UK general practice through the Additional Roles Reimbursement Scheme to improve access to musculoskeletal (MSK) care and reduce GP workload. While evidence suggests clinical and economic benefits, concerns are emerging regarding practitioner burnout and turnover. Understanding how contextual factors contribute to these outcomes is essential for sustainable workforce planning. To explore how the UK based FCPP role interacts with workplace contexts to influence practitioner wellbeing, burnout, and turnover intentions, and to identify implications for support and service design. A realist review of UK-based literature examining the implementation and experiences of FCPPs and comparable primary care roles was conducted in line with RAMESES standards. Initial programme theories were developed through stakeholder consultation and iteratively refined using published evidence. Data were synthesised into context–mechanism–outcome configurations (CMOCs), organised across four domains: role characteristics, personal characteristics, caseload complexity, and working environment. Thirty-three CMOCs were synthesised. Role ambiguity and poorly defined boundaries contributed to inappropriate referrals and role overload, intensifying an already complex caseload. These pressures were exacerbated by limited supervision and organisational support, leading to emotional strain, professional isolation, and increased burnout risk. Although practitioner experience and resilience could mitigate some effects, reliance on individual coping without adequate structural support undermined sustainability and contributed to turnover intentions. Burnout and turnover intentions among FCPPs arise primarily from systemic and organisational factors rather than individual shortcomings. Addressing role clarity, supervision, interprofessional integration, and workload alignment is essential to support practitioner wellbeing and ensure the long-term sustainability of FCPP roles. This review was registered with Prospero (CRD42024551933).