When reviewing the CPD portfolio in light of the current context of ACP I was faced with the dilemma of whether we need to have generalist, flexible programmes or a set of quite distinct specialist programmes to offer. Can one ACP programme fit all?
We have of course been here before. When I started as a CPD lead I was faced with a suite of programmes that had been developed to fit with the outcomes from the Darzi report. Most had a precursor of ‘Primary Care’ and was also followed by a specific field such as ‘End of Life’ and some also made it specific to a particular group of health professionals (most commonly of course- Nursing).
The difficulty with this was that we could never aspire within the limited resources of 1 university to achieve the complete range of specialisms that health care professionals working in the locality cover and wanted an education programme in. Of the range of programmes we offered it was common to see a very small number pursuing a particular specialist route each year.
The administrative workload involved in keeping a programme on the books was certainly burdensome. The sense of isolation and lack of peer support that students may feel if they are not part of a group going through the learning journey at the same time was worth some thought. As staff with particular specialisms moved on we risked having to close courses if we could not recruit someone from this particular speciality to take their place. I was also faced with whether I wanted to get into battles with other HEIs to compete over running a particular specialist course. If I did, this could actually increase the risk, both for my HEI and others. If we reach the point where Universities are not willing to take the risk of running a low number, high cost course the opportunities for people to study in a particular specialism could therefore become fewer and far between. So how could I justify these as viable courses to keep maintaining, promoting and running?
Many of these challenges are highlighted in the CoDoH ACP report and we are once again faced with this dilemma for ACP. Do we create a number of ACP programmes each with a specialism in the title, or do we create a ‘one size fits most’ more generic programme?
One of the obvious benefits of having a specialist field denoted in the title is it makes it easier to market the programme to your target audience. Up front you will be able to say something that assures people this is the right programme for someone working in that particular specialism.
The main attractor is often a specific short course or module that focuses on a set of clinical skills. Employers and students have consistently seized on the idea that x or y course is needed to work or extend their practice in a particular specialism. As long as it contains the right assessment of competencies, (sometimes these being endorsed or set down by reputable organisations working in that field), is at the right academic level, and has the opportunity to fit within a larger programme that leads to a post graduate award, the title of that award, it seems, is not as important.
So, do we need a Masters in Advanced Nursing Practice- End of Life in Primary Care? Maybe not. However, there is likely to be a demand for a module within a PG programme that focusses on End of Life and prepares them to apply the knowledge, skills, competencies for End of Life care to their professional field and working context.
Also, having a specialist descriptor in an award title just tells us that they are specialist- is this the same as being advanced in that specialism? ACP education should be designed to facilitate achievement and recognition at an advanced LEVEL. Being a specialist does not necessarily mean someone is working at an advanced level in that particular specialism.
To use the analogy of boiling an egg. I could be given the job in a kitchen to boil the eggs for breakfast and follow a set of basic instructions. In this instance I can say I am an egg boiling specialist as I am spending my time on one particular thing within a much bigger field of making a breakfast. However to say that I am an advanced egg boiler I would expect to be able to not just simply follow a set of instructions. I would expect to draw on evidence that tells me that the size of the egg and how cold the water is would affect how long it will take for the whole process to produce a boiled egg. I would also expect to be able to have the knowledge to pick the best tools to do the job most effectively, such as the size and type of pan to use. I would expect to be able to adapt the basic instructions to suit the particular circumstances each time I boil an egg, such as the particular preference of the customer as to how hard they like their eggs to be boiled. And finally, I would expect to have the experience, confidence, knowledge and skills to be able to train, support and lead others in developing this specialist task (not just hand them the set of basic instructions).
This of course reflects the 4 pillars of the ACP framework– research, education, clinical practice and leadership.
There is potentially a risk of heading too far down the specialist route in that we do not then leave enough space in the programme for all 4 pillars. We could have a very intensive programme that rigorously assesses a very long list of every competency to address every possible circumstance in that specialism. This may though squeeze out the time to needed to focus on developing critical evaluation and applying an evidence base in decision making, honing leadership skills to develop the specialism, and learning how best to support and educate others in this field or to provide space for reflective practice.
Of course, perhaps the largest elephant in the room is also a fact of reality- money makes the world go around! The way in which funding is distributed can be a powerful influence on what courses are developed, offered and are successful recruiters. So, if funding is tied to a specialist title, then you are likely to get HEIs offering courses in this area, if its linked to being able to be recognised as ACP then you can guess what may happen next. This will be the topic for my next blog.