PRISM: The PRimary Care Individual Social Norms MSK Data Dashboard: a Feasibility Trial

SUMMARY BACKGROUND AND RATIONALE

Over 20 million people in the UK live with a musculoskeletal (MSK) condition; accounting and one in three GP consultations . The Fuller Stocktake Report from NHS England described services as "stretched beyond capacity" with "signs of genuine and growing discontent" . The NHS, in keeping with the international trend to include non GP clinicians in the Primary Care workforce) have incorporated pharmacists, physiotherapists, practice nurses and physician associates within the primary care workforce to address the challenges of capacity and demand.

In the UK, patients with MSK problems consult a First Contact Practitioner (FCP) based in primary care instead of their GP, improving patient access to MSK management and freeing GP capacity . FCPs service in the UK, Sweden and Canada were found to be acceptable and effective in national evaluations .

The Chartered Society of Physiotherapy (CSP) and Health Education England (HEE) called for FCPs to be 'Advanced Practitioners' , a certification conferred officially on those with particular expertise. This was deemed necessary to meet the level of risk associated with having a clinical case load of patients who have not been screened by a doctor. However the pool of APs is limited and less experienced FCPs have been recruited into these posts.

FCPs in GP practices, work alone and lack the peer support of a typical physiotherapy department. Unfortunately, data suggests that less experienced FCPs are less likely to provide evidence-based MSK care. Clinical audits of FCP decision-making in over 2000 patients, from the Midlands and London, shows distinct differences in decision-making where Band 7 FCPs were almost twice as likely as Band 8 colleagues to send the patient to the GP for a second opinion, they underutilised 'social prescribing' and 'shared decision-making tools' and ordered more MRIs than their more experienced colleagues. The appropriate use of skills such as imaging requests and onward referrals should be utilised with consistency and in step with evidence-based guidance.

Evidence suggests supervision, social norms and feedback in clinical contexts can improve care. Specifically, that clinical supervision is an effective aspect of professional training and development that can improve evidence-based practice . It has been shown to support the effectiveness of care and reduce burnout and stress. A Cochrane review highlighted the importance of individual tailored feedback in supervision for learning and improving clinical standards. There have been calls for better use of data related to clinician performance, in clinical supervision eg, data on patient outcomes and experience and service level that show number of patients seen, follow up rates, resource use etc. This data has the potential to improve effectiveness by providing more formal and structured feedback on decision-making and quality of care . Presenting feedback about an individual's position in relation to their peers, ('social norms' feedback) can be used to identify outliers in clinical decision-making and nudge behaviour change. A recent systematic review and meta-analysis showed that social norms interventions are effective in "changing health care practitioner behaviours and improving patient outcomes". They nudge clinician behaviour towards desired standards and reduce variation in care . The potential of social norms interventions remains unexplored in MSK services in Primary Care.

In partnership with the Chartered Society of Physiotherapists and a network of improvement focused FCP services across the country, the investigators have worked to create a dataset that is comprised of retrospective FCP data that the investigators can analyse . Some of this data will be uniform as it was collected through a template in Emis and System one. The data collection template was developed as a collaboration between Keele University, the CSP and NHS digital physiotherapy leaders . Other services collected data through their own digital forms and local methods. They contain primarily the same metrics but with local variation. For the PRISM study the investigators will utilise the template where possible but the investigators can accommodate data that has been collected through multiple methods. As long as the datapoints capture the activity in FCP service, then it can be utilised for individual social norms feedback to FCPs in the PRISM study. This data is routinely available as it is collected for service level analysis. Although service level data enables knowledge at a provider level, it does not address variation in clinician performance or provide a mechanism for individual clinicians to reflect on their decision-making and change behaviour. The PRISM studies have formed a collaboration with industry partner www.VUIT.online.com to develop an interactive data dashboard which the investigators make available to all NHS FCP services.

Research Question:

To assess the feasibility of recruiting and retaining patients and clinicians to the study, collecting patient rated outcome measures and patient rated experience measures and assess the usage of the intervention, so that the investigators determine the feasibility of evaluating the clinical effectiveness and cost effectiveness of the PRISM dashboard in a future clinical trial?

Objectives: 1. To assess the feasibility of recruiting and retaining individuals and FCP teams to the trial.

2\. To assess the feasibility of collecting patient rated outcome measures (PROMs) and patient rated experience measures (PREMS)from FCP patients 3. To assess implementation of the data collection template in both arms of the study.

4\. To assess engagement of first contact physiotherapists with the PRISM dashboard.

5\. To assess the feasibility of measuring effectiveness of clinical supervision from the suprevisees perspective 6. To inform the protocol for a fully powered RCT to determine the clinical and cost-effectiveness of using the PRISM Dashboard and Guidance Document

Type of trial: Phase- Feasibility, single-blind, cluster randomised, parallel group, multi-site trial in Musculoskeletal patients.

FCPs and their supervisors in the intervention group will receive the password protected dashboard monthly via email link. The dashboard will contain visualisations of their clinical decision-making compared with social norms. The dashboard can filter to compare areas with similar index of deprivation.

Participants (FCPs and supervisors) will be given a Guidance Document based on the outputs of WP2. It will contain sections on how to interpret the data, information on evidence-based standards and resources to meet learning needs.

The FCP and their supervisor will review the dashboard in clinical supervision. The data can inform knowledge of the complexity of the caseload, outlier occurrences, common clinical behaviours such as decisions around investigations and referrals onward, as well as the clinicians use of the available spectrum of local services and interventions.

Trial duration per participant: Patient participants : Patient (Baseline, 3FU, 6FU) Clinical participants: Patient (Baseline, 3FU, 6FU)

Estimated total trial duration January 2026-September 30th 2026 Planned trial sites: multi-site. 4 sites Total number of participants planned: Investigators will recruit from 4 clusters with approximately 12 physios per site. Primary care areas will be allocated on a 1:1 basis. The sample of 4 clusters have been selected for the feasibility study as these are the numbers that are feasible to work with within the timelines and capacity of the ACAF award. A samples size calculation for the main trial has not been done as this is beyond the remit of this study.

Statistical methodology and analysis: The trial will be reported in line with CONSORT guidance. Analysis will be done by intention to treat principles based on clusters. Binary and other categorical measures will be summarised using frequencies and percentages. Continuous measures will be summarised using means and standard deviations (or medians and IQRs). All outcome measures will be summarised separately by study arm. Differences in outcomes between arms will be modelled using mixed effects linear or logistic regression models. Potential therapist effect will be assessed using the intraclass correlation coefficient. The precision of estimates will be assessed using 95% confidence intervals

Improvement to current practice It is essential to clearly identify opportunities to ensure that all FCPs can safely work toward MSK best practice standards. The unwarranted variation in care associated with skill deficits and low levels of peer support in the FCP workforce can lead to clinical risk and a negative impact on care. This protocol proposes a Primary Care Individual Social Norms MSK Data Dashboard - PRISM. The dashboard is shared with individual FCPs and their clinical supervisors. It is a social norms behaviour change intervention that aims to nudge clinician behaviour toward evidence-based standards and social norms by telling them, for example, the participant is in "the top 20% of MRI requesters", or "the top 20% of those utilising shared decision-making tools". It will report on the NHS England, 'Quality Safety and Effectiveness' measures for MSK Primary Care. In this case, social norms refers to the appropriate and expected behaviour of FCPs based on the behaviour of the majority and professional standards. This PRISM dashboard will be reviewed as part of supportive clinical supervision., allowing the FCP and their supervisor to discuss the data, reflecting on contextual factors such as caseload complexity, deviations from social norms and potential learning opportunities. By enabling FCPs and clinical supervisors to discover and address the learning needs of a clinical workforce, the investigators are creating a mechanism to identify and address unwarranted variation and thereby improve patient care.

Study design and setting:

This is a pragmatic feasibility cluster randomised controlled trial with embedded qualitative work package (described in WP2).

Setting: the trial will be set in UK general practices who have an FCP service. There is an ideal opportunity to evaluate the PRISM intervention within this existing national network. The study will be listed on the CRN portfolio. City \& Hackney Place Based Partnership, Primary Integrated Community Service Nottingham and Sandwell and West Birmingham Hospitals NHS Trust have expressed interest in the PRISM dashboard. Participating FCPs and supervisors will be blinded to their intervention for the first 2 months. After 2 months FCPs in the intervention arm will receive the dashboard and the control arm will not. Patients will be blind as to which group they are in. Outcomes will be collected at Baseline, 3 and 6 months.

Design This is a pragmatic feasibility cluster randomised controlled.

The Intervention The intervention is described in line with the TiDieR template for intervention description(54).

There are four parts to the intervention.

There are four parts to the intervention.

1. Data collection FCP clinical assessment and management data will be collected from FCP Clinics in EMIS and SystemOne for the purpose of comparing an individual clinician's behaviour with the FCP clinician group as a whole. In some cases this data is collected routinely already for service level data analysis. Some clinics use a template that was developed by the Keele MIDAS team with collaboration from the Chartered Society of Physiotherapists and NHS collaborators. This may be in intervention or the control arm. The template is used by FCPs at the end of each consultation and takes a maximum of one minute to complete. It is a summary of the consultation, with each tick-box being linked to the relevant Snomed codes to enable clean data extraction from the consultation record. The same data

• Feasibility - Number of Participants retained to the study at 3 and 6 months [Срок оценки: 3 and 6 months]
• Number of outcomes collected as a measure of feasibility [Срок оценки: 0,3 (patients)and 0,3 and 6 months (FCPs)]
• Completeness of outcomes as a % per outcome [Срок оценки: 0,3 (patients)and 0,3 and 6 months (FCPs)]
• Feasibility of recording the number of clinical supervision sessions that utilise the PRISM dashboard as recorded in a supervision log [Срок оценки: monthly for 6 months]
• Clinical Supervision Log [Срок оценки: monthly for 6 months]
• Feasibility of participants engaging with the dashboard intervention in a future trial [Срок оценки: monthly for 6 months]
• Feasibility - Means of collecting data per participant. [Срок оценки: monthly for 6 months]
• Manchester Clinical Supervision Scale (MCSS) [Срок оценки: 0 3 and 6 months]
• Clinical Activity data [Срок оценки: monthly for 6 months]
• EQ5D5L [Срок оценки: 0,3 months (EQ5D)]
• Cost per Intervention [Срок оценки: 6 months only]
• MSK HQ [Срок оценки: 0,3 months]