Published in The British Medical Journal - 20th May 2020

Rationale

A global health workforce crisis, coupled with ageing populations, wars, escalating costs and the rise of non-communicable diseases is prompting all countries to consider the optimal skill mix within their health workforce.1–6 The development of advanced clinical practice roles for existing cadres is one potential strategy that is being pursued.7–9 The origins of advanced clinical practice trace back to nursing in the USA and Canada in the mid-1960s, followed by the UK in the mid-1980s, then New Zealand and Australia in the 1990s.7 10 Advanced nurse practitioner roles evolved out of medical staff shortages, implementation of the European Working Time Directive (which reduced junior doctors’ working hours in the UK), changing healthcare population needs and increased ambitions for professional status and clinical career progression.11 More recently, other health and care professions have also adopted advanced, extended and expanded clinical roles12–17 and new non-medical cadres such as physician associates have been developed.18

In the UK, health has been a devolved responsibility of its four countries (England, Scotland, Wales and Northern Ireland) since the late 1990s and each country has its own ‘National Health Service’ (NHS). The NHS in each country is tax-funded services, providing universal health coverage, and, although some policy differences exist, they share many similar goals and challenges.19 Health services across the UK are actively exploring the development and implementation of new and advanced clinical roles to address workforce challenges and transform the way that services are delivered.20–25 For example, in England, an ‘NHS Long Term Plan’26 sets out a vision for healthcare for the next 10 years, which includes the development of new integrated systems of care that aim to cross traditional divides between health and social care sectors and related professional groups, and enable more efficient and innovative ways of working.27 28 New service models (referred to as ‘Vanguards’ in England and delivered through ‘Sustainability and Transformation Partnerships’) are taking a wide variety of forms.29 For example, some areas have integrated primary and acute care systems along with mental health services. Others have created multispeciality community care providers focused on providing better care and rehabilitation services for older people.28

Across the UK, plans have been developed to give an immediate focus on workforce actions required to implement such new models of care organisation and delivery.10 26 30–32 These recognise the need to invest in the development of new roles and advanced skills to enable workforce expansion—to be achieved by developing experienced professionals practising to the full extent of their education and training. This recognition has a twofold purpose: experienced health and care professionals will be enabled to work across professional boundaries and take on an extended scope of practice thus addressing workforce needs while also providing career development and rewarding opportunities to improve retention.21

Advanced clinical practitioners (ACPs) are now being developed throughout the UK across a wide range of professional groups such as nursing, pharmacy, paramedicine, physiotherapy, radiotherapy, occupational therapy and others (see online supplementary file 1 for a list of professions/occupational groups that are being considered for the purposes of this review).33 Across the NHS, these occupational groups are collectively referred to as ‘health and care professionals’.33 34 The term ‘care professional’ does not denote a specific professional role, but rather, refers to the fact that certain professions or occupational groups may work within or across a range of settings and sectors in addition to more traditional health services, for example, within integrated care systems, in social care, in the private or voluntary sectors (eg, care homes) or in criminal justice settings.33

Supplementary data

These UK-wide policy developments have brought to the forefront ongoing concerns around significant variations that exist in the definition, nomenclature, implementation, regulation and education of ACP roles across different professions and settings. In contrast to countries where there are clear routes for advanced practice education, credentialing and regulation, there is a recognition that in the UK, especially within nursing, there has historically been considerable and confusing variation in advanced level role titles, job descriptions and role profile.12 35 One recent UK study, for example, found 595 different job titles that denote specialist and advanced nursing practice roles. Likewise, there is currently significant variation in educational preparation across roles and in the content of existing advanced clinical practice training programmes.35–37 This variability impedes workforce planning and raises concerns about patient safety.36

In order to address these issues in England, the workforce transformation agenda is being supported by a national non-departmental public body, ‘Health Education England’ (HEE). HEE’s remit includes the education and training of individuals working at advanced levels through the development of advanced skills and educational training standards that can apply across a wide range of professional groups.26 In 2017, HEE published a Multi-professional Framework for Advanced Clinical Practice for England 33 providing a definition of ACP stating that: ‘Advanced clinical practice is delivered by experienced, registered health and care practitioners. It is a level of practice characterised by a high degree of autonomy and complex decision making. This is underpinned by a master’s level award or equivalent that encompasses the four pillars of clinical practice, leadership and management, education and research, with demonstration of core capabilities and area specific clinical competence’. The release of the HEE ACP Framework aims to support the implementation of advanced level clinical practice in health and related environments in order to ensure that health and care practitioners are supported in their role. The framework provides a basis to align existing educational curricula and competence frameworks and aims to create greater consistency across advanced clinical practice as well as inform new developments. The HEE ACP framework currently includes ‘consultant level’ practice, a role in the NHS Career Framework representing a more senior level of practice and service leadership that encompasses but goes beyond ACP capabilities.38 39 Within NHS Career Frameworks, advanced practice roles are deemed to be at level 7, whereas consultant practice roles tend to be level 8 (where level 5 represents the starting point for newly registered practitioners).40

The HEE ACP framework applies specifically to England, but has been developed in consultation with stakeholders that represent professions across the UK (eg, Professional Bodies and Royal Colleges) and has drawn on similar advanced practice frameworks that exist in the other three countries.23–25

As recognised in the HEE and other ACP frameworks, it is proposed that ACPs are educated to masters level (or equivalent) and have developed the knowledge and skills to allow them to take on expanded roles and scope of practice caring for patients (HEE refers to ‘masters level’ as an award that uses the relevant descriptors set at academic level 7 by the Framework for Higher Education Qualifications).33 41According to the HEE ACP framework, all health and care professionals working at an advanced level of practice should have developed their knowledge and skills to the level indicated in the core capabilities, across four pillars of advanced clinical practice: (1) clinical practice, (2) leadership and management, (3) education and (4) research.33 A key characteristic of professionals practising at an advanced level is the ability to work autonomously, thereby enhancing capacity and capability within multiprofessional teams. ACPs aim to improve clinical continuity, provide more patient-focused care and help to provide safe, accessible and high-quality care for patients.42

Across the UK, there are currently different ways to gain and develop advanced practice capabilities depending on the nature and scope of advanced health and care practitioners’ practice.33 In England, for example, as part of HEE’s drive to standardise advanced level practice, a national ‘Centre for Advancing Practice’ is being established. The Centre is a partnership between HEE and NHS England, NHS Improvement and other national stakeholders. The Centre’s role is to strengthen governance arrangements for advanced level practice by recognising practitioners working at an advanced level through two routes: (1) accreditation of university education programmes, and (2) an equivalence recognition route. Individuals and health and care providers may access different routes to evidence achievement of advanced level capability and competence through accreditation or recognition of prior learning, work-based learning.36 37

HEE is currently developing an approach to evaluate ‘equivalence’ that uses assessment processes established by the Academy of Health Care Science which defines equivalence as ‘a methodological approach where the outcomes of two processes are directly comparable even though the paths to achieving them are different. When equivalence is shown to exist between a new qualification and the qualification or experience an individual already has, further education or training becomes unnecessary’.43 The process of determining equivalence is a subjective process based on an individual demonstrating appropriate mapping of their training, education and experiences to a set of predetermined standards—in this case, the ACP Framework standards and HEE’s standards for the equivalence route.33 However, HEE’s precise methodology and approach for assessing equivalence are currently still under development.

As this national work commences, there is an urgent need to understand more fully the current context of, and evidence around, ACP across the specialties, sectors and the multiprofessional workforce in different roles across different care pathways to inform a baseline understanding of the contribution and challenges of ACP in the health service. This proposed scoping review seeks to address this need by identifying and mapping the current evidence base around ACP in the four UK countries. This will enable a UK-wide as well as country-specific picture of the current evidence on ACP to be identified.

back