The Multi-Professional Framework for Advanced Clinical Practice in England has set out an agreed definition and scope of ACP for the first time. It has done this, at least in part, by looking at what is already happening. This highlights that ACP, in its various guises, is not new and there are people currently working in ACP roles without formal recognition. So will previous experience count now that we are moving toward standardised routes of recognition for ACP? The answer is likely to be…well it depends!
Firstly we need to establish how will recognition as ACP be gained and what criteria will be used to confirm ACP recognition. As noted previously, currently the title ‘Advanced Clinical Practitioner’ is not regulated. In effect anyone could call themselves an ACP.
The way this is mostly controlled is through employers creating ACP jobs or developing roles within their organisations and then undertaking a selection process to choose who is moved into those positions. The framework now provides a standardised definition of ACP and the capabilities required, which can be used by employers as a benchmark to map against when creating or reviewing these positions.
In several reports that have been undertaken when considering regulation of ACP, it was found that ACP was a development of a persons practice rather than a completely new role.
“much of what is often called advanced practice appears to represent career development within a profession over time and not a fundamental break with a profession’s practice”
Council for Healthcare Regulatory Excellence, ‘Advanced Practice: Report to the Four UK Health Departments’ (2009)
The regulatory bodies have noted that their current requirements provide sufficient flexibility and set out clear responsibility for registrants to work within their levels of competence which may include advanced levels of practice. They have determined this is sufficient to maintain protection of the public, which is their primary purpose and has led to the decision not to add this to their list of regulated professional titles.
It is clear then that the responsibility for this currently lies with the employers and individual professionals themselves. If employers are to continue to be the gatekeepers to ACP recognition we need to assure ourselves that they will consistently take account of previous experience. It is though evident that not all people that potentially do meet these criteria or could be supported to meet the criteria hold current job descriptions. Whilst the quality of annual reviews in the workplace appear to be improving, the latest NHS Staff Survey notes there are still a good proportion of people, some of whom may fit the ACP definition, that have not had an opportunity for an annual appraisal or one that is robust enough to provide confirmation of capability. We therefore need to find a way that is able to recognise the development over time, to such a point where they now meet the capabilities required of an ACP. The Framework does give a useful flow chart and description of underlying principles to do this. However if we can’t even get to the point where people have a clear job description it is unlikely that we can aspire to have a consistent application of these principles in practice.
There is a temptation therefore to try to look for an external body to take on the responsibility for doing the checks and balances and managing the administration of gatekeeping. It has been common practice for organisations to seek external validation and get the tick in the box so they can proudly state they are a member of this or have been awarded that (think of the two ticks / Disability Confident scheme, or Athena Swan awards).
The benefit of this is fairly obvious in that it would provide a more consistent approach and remove the burden of assessment and administration from employers whose primary focus is after all health care provision rather than professional education, accreditation and regulation. However it also creates a question as to whether this would be the most effective way of recognising the development that has occurred through experience. Are external, distant bodies best placed to assess whether someone is practising on a day to day basis to the level required for all aspects of ACP drawing upon their knowledge, skills and experience to do so? As noted in my previous ‘generalist/ specialist’ blog post the large range of contexts in which ACPs operate does create a concern where some professions, specialties and locations are better served than others.
I expect with recent Covid-19 events the work for Health Education England to become such an external body for regulation of ACP is likely to be pushed even further back. However their initial focus would appear to have been on accrediting ACP education programmes in Higher Education Institutes. Whilst this is good news for those without previous ACP experience wanting to develop into ACP roles, and there would be an expectation that HEIs would include an element of Accreditation for Experiential Learning (APEL), we know already that this varies from university to university.
Each HEI can set it’s own rules and maximum limits for APEL. Quite rightly they are concerned about maintaining their reputation for quality and are therefore unlikely to award a degree to someone unless they have had some role in educating and assessing them. Expecting 100% allowance for APEL, regardless of how experienced someone is, is therefore unrealistic. 20-50% maximum allowance is far more common. We also have to remember that universities rely on income from students to continue to run. They would therefore expect to have enough input to the process to charge fees and make the ACP courses they run viable financially.
This does not leave much room for those very experienced people who over time have developed significant capability to satisfy the criteria for ACP. Using a portfolio approach to assess our experienced staff would be more appropriate for them. A Masters level award is a minimum requirement according to the framework. This will necessitate some, otherwise very experienced, people to undertake new activity to tick that box and gain that piece of paper as part of the portfolio, (whilst I am sure also benefitting from the supportive learning process this will offer them). However again it comes down to who would undertake the assessments and judgements on what is likely to be a very diverse range of people seeking recognition as ACP through a portfolio approach.
If the new Centre of Advancing Practice is not going to do this, it will be back to the employers to take this on. In these times of strain on health care providers it may be that our most experienced ACPs may be left behind in recognition of their role. The HEI accreditation route could be seen as the ‘low hanging fruit’ to at least get some formal recognition going. However we would not want to disenfranchise our most experienced members of this community in the process.
There is much therefore still to be determined as to how experience will count in recognition as an ACP and who will be involved in this process.