Abstract
BACKGROUND
In the United Kingdom, first contact practitioners (FCPs) provide direct access to musculoskeletal (MSK) assessment and management in primary care. This means FCPs have to assess patients with no prior medical screening, which assumes reliance on developed skills and experience. The pool of appropriately experienced physiotherapists is limited, and less experienced clinicians have been recruited. A 2026 national evaluation found substantial variation in FCP service delivery, with data collection and governance among its structural causes. The Primary Care Individual Social Norms MSK Data Dashboard (PRISM) dashboard gives FCPs feedback on their clinical activity relative to their peers to support reflection toward improving MSK care.
OBJECTIVE
This study aimed to co-design the metrics, filters, and guidance content of the PRISM dashboard and guidebook to reflect evidence-based practice and the real-world context of FCP roles, and apply a critical realist approach to identify the mechanisms and conditions shaping its design.
METHODS
This qualitative co-design study used a modified nominal group process across 2 online workshops in June and August 2025, with 10 purposively sampled participants: clinical FCPs, national physiotherapy and data leaders, and a patient representative. Two analytic strands were applied to the same data. The consensus process produced the metric set and filters. Critical realist thematic analysis of the transcripts using NVivo (version 12 Plus; QSR International), with line-by-line coding using inductive and a priori codes, identified the conditions shaping how those metrics would need to be interpreted.
RESULTS
Participants reached consensus on a core metric set describing the breadth of the FCP role, separating variation generated by clinical decisions from variation generated by structure such as local diagnostic access, prescribing rights, and referral pathways. Contextual filters were co-designed at patient, clinician, and service level to keep structure visible. Supervision emerged as a condition surrounding the dashboard rather than a component, since the same comparison prompts reflection where role clarity and psychological safety are present and defensiveness where they are not. A tool dependent on supervision would work least well where support is weakest. This means that an option for stand-alone use is a design requirement. Three data integrity risks were identified: recording reliability, data gaming, and clinician burden. The guidebook enables these conditions to be transferred into practice, with separate guidance for FCPs and supervisors and a 4-step reflection structure.
CONCLUSIONS
Expert co-design produced a metric set describing the breadth of the role while accommodating variation between services and acknowledging the conditions under which PRISM can function as intended. This paper moves from the national position that FCP services collect data to a specification of the conditions under which collecting data produces learning. Mapping of the metrics against National Institute for Health and Care Excellence MSK guidelines and quality indicators is reported in a companion paper.