Regulation of ACP- perceptions, evidence and the problems trying to be solved.

I’ve been reading the recent report that was undertaken on behalf of the HCPC regarding the review of whether to provide additional regulation of Advanced Practice for its registrants. The conclusion drawn is “there is no clear evidence, based on the findings of this research, that additional regulation of advanced level practice is needed, or desired, to protect the public”. This is despite the research revealing that 78.2% of participants believed that the HCPC should regulate ACP.  The reason for this juxtaposition of conclusions appears to come down to what has been widely reported regarding ACP; it is diverse, complex, evolving, variable.

Those that reported a support for additional regulation appeared to state the reason for this call was to address the lack of consistency widely experienced in ACP.  Variation in pay, scope of practice, training and support opportunities, education standards, access to ACP roles, as well as a lack of awareness and acceptance of the value of ACPs is undisputed. However, can and should regulation address the ‘problem’ of inconsistency and lack of recognition?

From the evidence I have found, no-one so far has been able to establish whether and what type of regulation would have a positive or negative impact on the development of ACP. Globally different countries are at varying stages of ACP development, including use of a range of regulation (Carney 2016).   The USA is often quoted as the place where ACP first developed at scale, and is known to have widespread regulation in place.  Yet, even here, there is variation between different states and a confusion of different titles and scope of practice (Heale and Reick Buckley, 2015).  There is not therefore a model we could pick off the shelf and apply to the UK, especially considering the particular health system and professional context that operates here.

This begs the question, does regulation assure consistency? If we look at the existing regulation for health care professions we can see that it does not address fully the problems we are trying to solve with ACP. For example, despite all Nurses being regulated, pay varies considerably across different sectors of the health system, with those working in the primary care, independent, or other sectors not falling under the ‘agenda for change’ standard rates of pay for particular types or levels of work. In addition, the HCPC and NMC, as the two largest UK regulatory bodies of health professionals, do not address through their current regulation whether training, support or job opportunities are equally accessible to all. This often depends much more on the resources and opportunities available at a local employer level. 

These regulatory bodies do though provide a role in setting and monitoring the over-arching standards of education in the professions they regulate. It would however, be hard to argue that Health Education England (HEE) and their Centre for Advancing Practice have not already stepped into this role for ACP. The establishment of the Multi-professional framework for advanced clinical practice in England (which mirrors the standards used in the other countries of the UK) has set the bar for expectations of ACP education programmes. The fact that HEE also hold the purse strings for commissioning ACP education means they can monitor and control what education opportunities are available. This, combined with the ACP apprenticeship standards set by the Institute for Apprenticeships and Technical Education (which maps directly to the framework) and monitored by Ofsted , appears to address the issue of knowing what to expect from an ACP education programme. These initiatives are at the early stages of implementation so time will tell if this is successful. As with all new initiatives sufficient time should be allowed for this to be evaluated before a new initiative (such as further regulation) is added.

In these times when we have been so often confronted with our ineptitude in embracing diversity, (e.g. the Black Lives Matter and LTBQI+ campaigns and health inequalities exposed by Covid-19) there is also the risk that our pursuit of homogeneity will exclude some of the ACP population. The NHS people plan notes that we need to encourage and support the development of new ways of working and innovative roles to achieve the objectives of ‘growing for the future’. We have already seen that some professions and clinical specialisms within the ACP community are more readily supported and recognised than others, which is not helped by the existence of credentialing frameworks, education programmes and accreditation processes for some, but not all of the diverse range of advanced clinical practice. Certainly regulation to date has not resolved the public confusion regarding health profession roles, including male nurses and ACPs often been called doctor and female doctors having their professional title used less often than their male counterparts.

The findings of this research is therefore enlightening, as much by what it notes needs to be researched further due to insufficient evidence, as by what it has found. We will await the outcome of the NMC and HCPC reviews for ACP. We can of course expect them to focus on its core purpose as a regulatory body, which is to protect the public and therefore undertake/ omit actions that advance this cause. So far regulatory bodies have noted there is not evidence to say the public are at higher risk by receiving care from ACPs. There is extensive research that has highlighted that the clinical effectiveness outcomes of ACPs compared to other professions (usually medical professionals) is at least as good as, if not better.

Will they stand firm and say that regulation cannot resolve the ills that are facing ACP? Will the desperate cry for equal recognition and fair access to opportunities force their hand to accept perceptions that regulation can be the knight in shining armour to save the day and be the persuasive evidence to introduce additional regulation for ACP? Will the current government stem the tide of calls for more regulation and intervene on their mission to reduce bureaucracy and de-regulate health professions? We shall see….

You can also read my commentary piece published in the British Journal of Nursing ‘Advanced Clinical Practice: Is it worth the bureaucracy?’

Published by vjscottcpd

Vikki-Jo was Head and then Dean of School for Health & Social Care (formerly Health & Human Sciences) since 2013 until 2019. She is a registered Nurse with a background in Critical Care Nursing. Since working in academia she has focused on Continuing Professional Development for Health and Social Care professionals. She is a Senior Fellow of the Higher Education Academy with a Masters in Learning and Teaching. In 2020 she commenced her PhD focussing on Advanced Clinical practice education. At this time she also returned to working in Critical Care during the Covid-19 pandemic.

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