Written evidence Submitted by Ms Vikki-Jo Scott, Senior Lecturer and PhD student at the University of Essex, School of Health & Social Care (RTR0001)
I am providing this evidence from the work I have undertaken regarding the value and impact of Advanced Clinical Practitioners in the UK. I have completed a systematic literature review on the subject which has been accepted for publication by the British Journal of Nursing, but is not yet published. The evidence I provide here is based upon the findings of this research.
This evidence addresses the following question posed within the Terms of Reference for this inquiry: Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?
Advanced Clinical Practice (ACP) begun to emerge in the Unites States from as far back as the 1960s (Dunn, 1997). Examples of developing trained health care professionals to take on additional advanced tasks and skills or extended roles can now be found globally. Initial development of Advanced Clinical Practitioner roles is typified by a need to reconfigure services to address unmet need. Common examples are substitution for a short supply of medical professionals, or to develop new ways of working such as the shift from emphasis on acute-in-hospital health services to delivery of primary, community-based health care.
In 2017, a number of professional bodies collaborated to create the ‘Multi-Professional framework for Advanced Clinical Practice in England’, (Health Education England, 2017). This has been followed by an increase in activity around ACP:
In the ‘Growing for the future’ section of the NHS People Plan (NHS Improvement, 2020) it specifically cites Advanced Clinical Practice as key to “addressing the most pressing workforce shortages in those service areas with the highest demand and those professions that require urgent focus”. It highlights the significant investment in this workforce by providing an additional 400 entrants to training programmes. The Faculty of Advancing Practice for the East of England has also recently set out the additional funding that has been made available in this region. They note that this is being provided on the basis that “a key driver for the implementation of advanced practitioner roles is to enable practitioners to work at the top of their licence, reaching their full potential and optimising their contribution to meeting population, individuals’, families’, and carers’ needs through different models of service delivery and multi-disciplinary working.” (Health Education England, 2021b).
In an on-line workshop that gathered over a thousand responses from ACPs, “concern was expressed that a degree of certainty was needed about the future of advanced clinical practitioners if professionals were to invest their time in developing their skills and qualifications and if employers were to provide their investment and planning.” (Health Education England, 2020). From the literature review conducted, the certainty that is being asked for here is far from being present in current evidence as it consistently highlighted the diversity of the ‘in practice’ reality of ACP.
Whilst there emerged a broad consensus on ACP about the definition, they noted the variability of and ‘localisation’ ACP (including the scope of practice, training, education, regulation, and renumeration). There is an absence of evidence that directly studies ACPs in localised contexts and what they believe to be the personal benefits of becoming an ACP and evaluation of whether these are being achieved.
Data on the full costs and outcome measures of ACPs is sparse, often missing inclusion of the cost of education, or collection of longitudinal data on outcome measures. There is a body of evidence that does support that ACPs provide positive clinical effectiveness outcomes (e.g. reduced waiting lists, patient satisfaction etc) that are at least equivalent to other roles (such as junior doctors). However, the research also highlights that the grading, salary scales and remuneration of ACPs varies considerably. Barea’s study (2020) showed no clear correlation between the pay awarded and the career pathway, training, or education route ACPs had followed to be in their current role. This, combined with variety of education routes (and thereby costs to support development of ACPs), makes drawing any broad conclusions about cost/ benefit analysis of ACP in the UK difficult.
A consensus was found regarding the barriers and facilitators that by their presence or absence affect full realisation of the potential benefits of ACPs, effective implementation, or measurable positive impact on outcomes. Over half of the papers in the systematic review included identification of barriers or facilitators of implementing effective advanced clinical practice or advanced clinical practitioner roles, which influences the impact they can achieve. The range and currency of many of the papers appears to also provide consensus that despite knowing about the barriers to effective implementation of ACP, they are still prevalent, and the facilitators are often not considered when planning development of an ACP role, (e.g. Miller et al. 2009 , Thompson et al. 2019).
Three overarching themes regarding barriers to ACP were found:
Access to training and education
Duffield et al. (2009) highlight the ‘adhoc’ way in which ACP roles have developed and that this has created a “confusing overlap” in many areas. They claim that a lack of consistency in education has hindered efforts to make full use of these ACPs in health care. A number of authors also highlighted that there is a need for sufficient availability of appropriate interprofessional and financially viable education and training to provide the skills necessary to fill ACP posts. Without this it acts as a barrier to development and implementation of effective ACPs.
Inadequate protected time for education is commonly identified, and is often related to one of the other major findings of this review; that clinical practice dominates the role and the time allocated to duties/ tasks within this role (e.g. as cited by Llyod Jones 2005, McConnell et al. 2013 or Read et al. 2001). It was commonly reported that clinical demands took priority and that opportunities for development and education were missed if a clinical task was needed. In Currie et al. (2012) and Williamson et al. (2006) research it was noted that the “pressures of time” restricted the participants ability to effectively engage in aspects of their development and education.
Support from others for role expansion
The review highlighted that medical staff had a significant impact on the development, implementation, level of autonomy, management and operation of the ACP role. Miller, Cox and Williams (2009) talk of the need to ‘win round’ physicians if the role was to be considered as a worthwhile endeavour, to remove anxiety of ACPs ‘taking over’, and thereby attract the funding and managerial or organisational structures to facilitate the role. Where support was not in place, ACPs often found they were unable to operate the full extent of the role and utilise the knowledge, experience, and skills they had gained. McConnell et al. (2013) correlated this with a lack of engagement in managerial or leadership functions of the role, including development of policy.
De Bont et al. (2016) and Thompson et al. (2019) discuss how the perception and understanding of the role, particularly by physicians and employers, had a major influence on how, what, and where ACP roles were developed, even in situations where specific policy or protocols were in place to ensure consistency.
They also note personal relationships can be key and that this may require a long time to build up; ‘trust’ is required between professions to allow the sharing, re-allocation, or shaping of health care services, roles and tasks. Elliott et al. (2016) and Lloyd Jones (2005) found that the presence of a role model, mentor or support from senior managers, combined with opportunities to receive feedback or engage with a peer network were powerful enablers of the role. However, the reliance on support from others makes the ACP role precarious as it requires professional relationships built up over time; if a supportive member of staff leaves, the ACP role may not be able to continue to develop or operate as it had done before (Miller, Cox and Williams, 2009).
Organisational structure, policy and protocols
Lloyd Jones (2005) and De Bont et al. (2016) note that familiarity within an organisation and ‘localisation’ extends even in situations where national, professional or organisational level policy is in place and that local arrangements may restrict ACPs from undertaking their full range of the role and the skills they hold. This includes protocols that define the path of clinical intervention, including what tasks are undertaken by whom (e.g. as described by McConnell et al. 2013). De Bont et al. (2016, p. 8) note that “The differences in tasks and responsibilities, the organisational embeddedness of practitioners, and the situatedness of the work, limit further development of extended professional roles, and may even lock professionals into their work place.“ This of course could therefore restrict innovation to address service need and provide a disincentive for individuals to pursue a role as an ACP or be retained in that role.
The impetus for the development of the role is seen as significant in providing the organisational structure in which ACPs operate and, as Thompson et al. (2019) highlight when ACPs have been bought in to ‘fill the gaps’ rather than work flexibly or to create a new or reconfigured service, this can impact the scope of their role.
On a more functional level Elliott et al. (2016) and Read et al. (2001) noted that lack of access to administrative support funding and resources for data management affected the fulfilment of the role, particularly leadership aspects. They also point to a lack of authority and position within an organisation because ACPs often sit outside of traditional hierarchical and committee structures, which impedes their influence on strategic decision making.
Lloyd Jones (2005), Thompson et al. (2019), Wilson-Barnett et al. (2000) and Miller, Cox and Williams (2009) highlight the need for clear communication of role definitions, job descriptions, and boundaries to reach consensus on expectations and facilitate transition into ACP roles. The lack of clear agreement within the current or traditional organisational structure is noted as a potential barrier, with the risk that it is seen as a ‘dead end job’ or a ‘career cul-de-sac’ Smith and Hall (2003). The lack of engagement with, or opportunity for non-clinical aspects of the role may reinforce this, with few options for these health professionals to progress in a clinically dominated career.
What can be done to address this?
These can be summarised as:
-Time off for training - Co-ordinated workforce planning
- Investigation of regulation - Organisational and leadership mandate
Time release away from clinical activity was seen as critical to ACPs being able to engage in development activities. The challenge is therefore to find a way to support the ‘whole costs’ and development needs of ACPs for them to engage effectively in training and education. Consideration should be undertaken as to how learning can be supported when conflicting pressures on ACPs time is likely to impact their ability to dedicate time to study.
This points to a need to establish mandatory expectations regarding ‘time off for training’ that is separated from addressing clinical demands and provision of funding to support backfill costs.
There appears to be agreement that regulation may be a way to reduce variation and confusion over education and career pathways for ACPs, (Duffield et al 2009, Heale & Rieck Buckley 2015, Marsden et al 2003). Heale and Rieck Buckley possets that in countries where there is less developed regulation the presence of barriers are higher, however the data to corroborate this statement is not presented in the research, only data that confirms that variation exists is presented. The work conducted by Leary et al. (2017) which more broadly looked at titles used within nursing found proliferation, inconsistency, and poor clarity which they concluded could be attributed, at least in part, to lack of regulation.
Conversely, Delamaire and Lafortune (2010) point to the lack of regulation in the UK as facilitating adaptation to the scope of practice which enables ACP roles to be effectively implemented at a local level. This was though not directly measured in this research.
Read et al noted in 2001 that regulatory bodies appeared to have rejected the idea of adding a new level or type of regulation for their ACP members because of the belief that their regulation already covers practitioners to develop along a continuum, including advanced practice. This was further endorsed by the Council for Healthcare Regulatory Excellence in 2009 and there continues to be no unified national regulation of ACP and the somewhat newer introduction of ‘credentialling’ as an effort toward standardisation, remains patchy (Health Education England, 2021a). The Nursing and Midwifery Council have however launched a consultation on post-registration standards for education, (Nursing and Midwifery Council, 2021).
Consequently, there is insufficient longitudinal evidence found in my review that directly assesses whether regulation is a barrier or facilitator specifically of ACP, or what types and degrees of regulation may be more or less effective in realising the benefits of ACP. Further research that particularly focuses on the impact of changes to regulation of ACP may provide evidence to support or reject changes to regulation. (For example research that investigates the impact of the work being undertaken by the Centre for Advancing Practice by Health Education England introduced in 2020, or the independent research conducted by Hardy et al, 2021 regarding regulation in the allied health professions).
This would align with the outcome from the government consultation on ‘Busting bureaucracy: empowering frontline staff by reducing excess bureaucracy in health and care system in England’, (Department of Health and Social Care, 2020), where it was noted that regulation “needs to be focused and intelligence-driven”.
In this consultation it was heard that “time spent on ‘unnecessary bureaucracy’ takes staff away from patients and service users, and is likely to reduce the potential for innovation and staff wellbeing and satisfaction, impacting on job retention and productivity”. It identifies overly complex regulation as an issue and a trend that is getting worse. As a group of individuals that work in multi-disciplinary teams, in a variety of contexts, and that cross a variety of professional, and therefore regulatory boundaries, ACPs would easily fall into the category where they have to repeatedly respond to similar yet different requests from a wide range of regulators, commissioners, and managers, particularly if further regulation was introduced.
In the continued lack of regulation and confusing context of career pathways this places the burden on the employer to shape the scope of practice, pay, grade, outcome measures, training, education, support and development of ACPs in their organisation. Lloyd Jones (2005), Wilson-Barnett et al. (2000), and Thompson et al. (2019) noted role ambiguity which can be exhibited in poorly defined job descriptions and lack of standardisation against definitions. This could be addressed by providing a centralised mandate of the expectations regarding ACP and co-ordinated workforce planning (e.g. through Integrated Care Systems). Some aspects of this are being addressed through the Centre for Advancing Practice, although they are limited in their scope (e.g. in enforcing expectations regarding pay, grade, job descriptions, supported career pathways, and time off for training).
Clinical practice dominates over the other 3 pillars of ACP: leadership & management, education, and research. (Elliot et al 2016, Read et al 2001 and Gerrish et al 2011). This is also born out in more recent research conducted and reported outside of this review (Lawler, Maclaine and Leary, 2020).
For employers that are wanting ACPs to contribute and add value to these aspects of managing and delivering a health service, this creates a challenge. Elliott et al. (2016) highlights that for this to change, greater presence of ACPs on committees and organisational structures at a leadership level are required to be facilitated and ‘built in’ to the role from its inception. Consideration of reporting structures within the organisation, and basic resources to facilitate the role (e.g. administration support) is also needed.
Advanced Clinical Practitioners are a valued and expanding part of the workforce that are being prevented from realising their full potential. This limits the opportunity to use this role as a way to meet the objectives of the NHS people plan, particularly in retaining a highly skilled workforce that can innovatively reshape health and care services to meet the needs of the population. The barriers to their effective implementation are well known. Strategies to address time off for training, proportionate regulation, co-ordinated workforce planning and a mandate to allow them to operate at an organisational, policy and leadership level is needed to effect positive change.
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