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Reflections on Advanced Practice Week

Credentialing, confusion, communication, collaboration, and country lanes.

This month I have been reflecting on the various activities and conversations that happened in the ‘Advanced Practice Week’ that occurred between the 9th-13th November.

This included the Health Education England ‘Advancing Practice-Taking Centre Stage‘ conference, Twitter chats, Facebook queries, and making new connections with people working in this area. There was a lot that provided encouragement about advanced clinical practice.

Consensus on the place of research in ACP was clearly voiced. Supervision as a way to support ACP was welcomed. Some brilliant examples of the positive impact ACPs can make to clinical effectiveness were also shared. (For example Heather Rimmer’s service evaluation of ACP’s experiences of emergency redeployment to intensive care during Covid-19). This appears to show significant progress being made in the world of ACP. The fact that the conference had to close to offering places due to its popularity means that there is a large body of people that are engaged in ‘all things ACP’.

However, there is of course the concern that we are ‘preaching to the converted’. Those that signed up for the conference or got talking on Twitter are people that are already invested or ‘sold’ on the idea of the positive impact that ACPs can provide and are aware of the work that needs to happen to make the most of this body of health professionals. In comparison, it was interesting to see the questions that keep popping up in other forums, (e.g Facebook groups) that are populated by those that maybe on the shop floor of ACP rather than those you will see on more ‘academic or managerial forums (such as national conferences and Twitter feeds). Repeatedly questions continue to arise about what is required to be able to be recognised, gain employment, and be supported in ACP roles. This indicates the answers to these questions are not being clearly communicated or are not yet known.

In a recent 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.”   From the literature review I have recently conducted, the certainty that is being asked for here is far from being present in the current empirical evidence.  This evidence is dominated by descriptions of ACP and highlights the barriers and diversity of the ‘in practice’ reality of ACP. 

In response to the specific call made in the NHS people plan, there now appears to be a ramping up of the development of ACP credentials. As noted in one of my previous blogs, this may start to fill some gaps in the current situation of some specialisms, professional groups, or fields of practice being left out from the current patchy set of credentials already out there.

And yet… there remains calls of what about me and how far do we go? For example one participant in the ‘Taking Centre Stage’ conference asked “Credentials feels like CPD but also puts people into little boxes with fixed scope. If we have pelvic health where does this stop? Are we going to have one for every system!?”

Does this mean that a whole new industry is being created where every minutiae of clinical practice will need a credential to validate against? How sustainable is that, when we know that part of the role of ACP is to be innovative and to develop practice? The credentials we produce now are unlikely to be fit for the future in the long term. Perpetual writing and re-writing of ACP credentials could become a major industry!

Alternatively having just broad credentials to cover the main fields of practice might give the majority a place to call home. However, it is unlikely to fully reflect the complexity, intersectionality and diverse community that is ACP. This will always leave someone out that doesn’t quite fit, and will not provide the detail of knowledge, skills, capabilities, and competencies that are required to do that ACP role, in that service, in that place at that time. For this, the situatedness or localisation of ACP (as discussed by DeBont et al) remains a clear feature, and one that will need addressing at a level much closer to home between ACPs and the people they work with than a nationally produced credential could ever achieve.

And yet… people continue to ask but what about this route, or do I need to get that piece of paper, or follow that process to be able to work and be a valid ACP.

This is compounded by the different bodies that appear to be offering a route to recognition, and trying to demonstrate that their one is the best way to go. It was encouraging to hear of the promises being made regarding collaboration between these bodies to try to reach agreement about transferability. (The idea being that if you have completed a process through one, like the RCN credentialing process, this would also be recognised by the other, like the Health Education England’s accreditation, and won’t be superseded by a change made by a regulatory body such as the HCPC). However, so far nothing definite has been confirmed. The concern therefore remains that each body, who have their own personal interests (such as control of ownership of setting standards, and retaining a funding pipeline to support their work), do not really have the commitment to come to an equitable solution to this, and we may have put the cart before the horse.

So has the call for certainty to allow people to make the right decisions about their development in ACP been addressed? I think it is too early to say; there is more work to be done. My advice, to anyone that asks, is therefore to tread carefully. Look at all the options, scan the horizon, get objective advice, and weigh up the alternatives that work best for you within the resources and constraints you have. (i.e. it’s not so simple, it’s more like a network of country lanes to navigate than a nice, straight, fast, 4 lane motorway!)

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ACP- Bureaucratic Blockages?

In my last blog post I asked what next? Well its been a bit busy since then in the ACP education world with the doors opening for Universities to apply for accreditation of their ACP programmes and the freshly published People Plan making specific reference to CPD and ACP. One of the largest regulators of health care professionals in the UK (the HCPC) has signalled their intention to look again at the evidence for potential regulation of ACP. And we’ve also had NHS workers (including ACPs) excluded from the pay rises given to other public workers in the aftermath of the C-19 crisis. The people plan notes as one of its key messages that bureaucracy falling away in this time has helped people to feel empowered to do what is needed. So is this context reflective of the ACP experience? Have bureaucratic blockages been removed to allow ACP to be implemented effectively? I’m not sure it has.

In my last post I gave an example of how I witnessed first hand an ACP work really effectively and in more extensive and expert ways than even she realised. However I am not sure if this was because the barriers that may have previously been in her way had thoughtfully and systematically been removed due to policy change. Was it just necessity as there was no-one there to tell her otherwise, and would her position and scope of practice that she was ‘awarded’ in this time be sustained? I would like to think so.

Covid-19 has forced, nudged, or more generously, allowed us to operate in different ways than we had before. But the hard work now may be to effectively evaluate whether this was a positive change, and if so how this can be sustained.

I’ve been reading a lot of research on ACP, where….

1. we know what benefit ACPs can bring

2. we know the principles of how to effectively implement ACPs

3. we also know the barriers that prevent ACPs working well

….but…….the barriers are still there and there is still evidence of ACPs being prevented from achieving their full potential.

The principle of removing barriers, (particularly bureaucratic ones which arguably are there not for any sound justification) is a good one. In ACP this could be ensuring people have equal and easy access to CPD, supervision and protected time for training. It could be ensuring people that may stand in the way of ACP development, potentially out of an undue sense of needing to protect a profession are ‘enlightened’ to the merits of supporting ACP development. It could also be making sure people are given the recognition and remit to do the work they have the knowledge and skills to do by creating jobs, teams, clinical pathways to allow this to happen. This all sounds good, right, what’s needed.

What I’m not sure of is how some of the recent changes in policy, context or practice help us to get there.

Equal, easy access to CPD with protected time for training requires backfill, as the People Plan highlights. Do we have the skilled workforce and the money currently to do facilitate this? A large amount of the media such as the recent RCN report of staff shortages questions this. My own experience is that working through NHSP to continue to support colleagues in ITU past the peak of Covid, has been stopped due to financial concerns of agency staff costs. But this is still whilst they are facing staff shortages due to sickness, sheilding or self-isolation, and the ‘normal’ work of ITU ramps again.

Ensuring colleagues understand the merits of ACP and the full scope they can offer so they become a facilitator rather than a barrier may go either way. It could be that the crisis way of working has opened people’s eyes and with renewed vigour we can embed more formally the ACP role in our services. Or it could be that as things return back to more routine work, the ‘re-deployed’ are returned back to their original boxes.

Recognition can happen in many ways. A clap on a Thursday was nice whilst it lasted but appears to have turned sour and momentary, spurring many on to campaign for such gestures to turn into something of more solid value. Will the accreditation of ACP programmes provide that recognition? From someone going through the paperwork required for this process, I am conflicted as to whether this is just another bureaucratic barrier for ACPs to pass through or whether it may actually remove a barrier by facilitating national recognition against a set of ‘guaranteed’ standards. The HCPC makes the promise that any measures taken as a result of their current investigations regarding additional regulation of ACP “should enable, and never restrict or serve as a barrier, to effective development of registrants advancing their practice.” Will this translate into creation of more ACP jobs?

The people plan refers to 400 extra ACPs in training but not whether this will translate into new positions and whether that is enough for what is needed and to recognise the potentially large number of people that are/ can work at ACP level?

So I’m left feeling there’s lots of aspiration here. We have the basis on knowing what ACPs are and what they can offer. We also know the things that may help or hinder that progress. But is this just full of promises without the opportunity and right ingredients to make it happen? As with many right now I waver between optimism and pessimism but ultimately a lot of hope that there is enough energy left for us to overcome the barriers, bureaucratic or not.

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Advanced Clinical Practice- where next?

I want to start this latest blog post with an apology for the hiatus. As many of us have got used to hearing over the last few months a little thing called Covid got in the way a bit! I ended my last post with the question ACP-where next? So I thought it would be helpful to say what I’ve been up to since the last post and where I think this leads us to next.

Back at the end of March the opportunity for me to return to clinical practice as a Critical Care Nurse presented itself in the form of the ‘Covid crisis’. Whilst this meant that I was somewhat distracted from my plans for this blog it did afford me a unique insight to witness first hand ACPs in action. For me, this provided perfect illustration of what I’ve been reading, learning and thinking about ACP.

After 18 years away from the ‘front-line’ of clinical practice I found myself working one day with a critical care nurse, (I’ll call her ‘Amy’), that had been in the midst of her ACP training when C-19 hit. What I witnessed was a true epitome of the 4 pillars of ACP in action (clinical practice, education, leadership and research).

She became an excellent educator to the (obviously nervous) redeployed staff; something she would never have thought she would need to do so extensively. Staff frequently looked to her to provide leadership in unfamiliar, unprecedented, and scary times. She expertly provided this with clear and supportive instructions and decisions. In coffee room debates of ‘what’s new about Covid-19’ she often was able to refer to an evidence base to support what she was saying, to dispel myths, and propose areas that were uncertain and would likely feature in future research or evidence to come out of this time.

However she also talked to me about her worry that her training had been suspended and that she was trying to think of different ways to meet the (highly demanding) list of clinical competency assessments required. Being in critical care she is in one of the few groups where a set of credentials have been set down to be able to be recognised and practice as an ACP in this field (FICM).

What struck me was that she was so focussed on the clinical competencies and so nervous about getting these right, and was worried about missing opportunities to practice and be assessed in them, that she was perhaps ignoring how she was brilliantly demonstrating what it means to be the true embodiment of an ACP!

I just wanted to say don’t worry, those clinical tasks will come, there will be opportunity for that, and over time new ones will be needed and other ones assigned to the discard pile. What you are doing now is astounding development as an ACP with knowledge, skills and experience that will last you a life time.

We also talked about the potential barriers the future holds for her to utilise the full range of her ACP role. During this time I have also been completing a scoping review of the evidence of the benefits of ACP education, and unfortunately this is a fear that has got significant foundation to it. Clinical practice tends to dominate ACP work and factors such as the way in which ACP roles are organised and developed, and the willingness of colleagues to relinquish tasks and offer autonomy to ACPs can restrict their practice.

This experience and my findings from the scoping review are leading me to think more than ever ‘what’s next for ACP?’

What is clear is that we do not need to repeat the multitude of studies that defines or sets out the potential scope of ACP. The barriers and facilitators to effective development and implementation of ACP are well known. The positive impact that ACPs can have on clinical effectiveness outcomes, including patient satisfaction and measures such as reduced waiting times has been evidenced. The impact on costs depends on whether ACPs are being used to substitute for others (usually Doctors) or provide a supplementary service and ‘add value’, which has often not been measured over long enough to really evaluate the impact. (The OECD working paper on Nursing in Advanced Roles provides a useful summary and exploration of these themes).

What is less clear is where people like the ACP trainee I worked with are heading next. Will they be able to realise the various benefits that I talked about in my first blog post, such as remedying staff shortages, or providing a satisfying career development route for our most skilled, experienced and advanced practitioners in health care?

The recent on-line HEE Advanced Practice workshop held to gather experiences of ACP in this pandemic may help to signal what we can expect from ACPs in such times or in the ‘new normal’ we are all adapting to.

Now the first peak of C-19 appears to have subsided in my part of the world, I am turning my attention back to my research and work as an educator in ACP.

I am still not sure what is next for ACPs, but believe from my research, work, and experiences so far that attention needs to be paid to evidencing the purported benefits of ACPs for those that are interested in/ being encouraged to follow this career route. If people like Amy are to fully realise her potential and the health service is to benefit fully from people like her we need to assure her that she is following the right path. So this questions… is ACP the way to go?…I’ll leave that question to explored in a future blog.

Advanced Clinical Practice- Map Finding

There has been a long history of calls for definitions of, and agreement on, what it means to be an Advanced Clinical Practitioner.  Several notable ones have emerged such as the statement of NHS employers which references the Multi-Professional Framework for ACP in England or the International Council of Nursing’s Advanced Practitioner Nursing Network definition (AAPN).  This has perhaps paved the way for employers to establish specifications for recruiting to ACP posts and monitoring performance.  For commissioners of ACP training this gives a benchmark to choose which education providers to use.  For professional bodies and communities of practice this may also provide a set of standards which if met means they can add their stamp of approval and recognition.  What this means for the individual seeking to become or be recognised as an ACP though, is that they have to find their way amongst these definitions, specifications, benchmarks and standards to match their knowledge, experience and skills against them. 

So is there a clear map to do this?  I am afraid that here again the answer is…well it depends!  Whenever planning a journey you should ideally know where you are starting from and where you are aiming to get to. It’s common that we start in different places and of course we therefore have to follow different routes to get to where we want to go. 

You can control somewhat the starting points by restricting the places of entry.  In terms of ACP, the entry point is that they are already working in clinical practice, and recognised as a health care professional. 

There is an element of ambiguity here in that globally the heath care professions are defined differently, called different things, have different scopes of practice, and some have professions that are new or emerging or not common in other places.  For some professional groups they follow much of the standard route to gain recognition and entry into working in clinical practice but are not yet a regulated profession (for example Sports Therapy).  There may still be some debate therefore as to whether there are equal and clearly defined entry points for ACP.

Another of the entry points is the criteria which have to be met in order to commence on an ACP education programme.  ACP education programmes are now commonly defined as needing to be at Masters level.  As established in my previous post, universities that provide these programmes set differing standards in terms of recognition of previous qualifications or experience as a gateway to these programmes.  For some they would require that an undergraduate degree has already been successfully completed.  For the majority of health professions that have trained in the UK it is now standard to hold a UG qualification as entry to the profession.  However what about those that trained before this was a requirement, or those that have trained in other countries where this was not a basic requirement?  This opens up again the question of to what extent experience counts to gain the basic entry to the journey to become an ACP.

In terms of the destination, you could assume this is much easier to agree on; the aim is to achieve recognition as, and employment in, an ACP role.  Without an over-arching body that ‘gate-keeps’ who is recognised and who is not an ACP, there is though potential inconsistency and divergence on where we seek that recognition and whether all agree on this so it can be globally transferrable.  If we just look at the UK, or even regionally, we would not want a set of criteria for ACP recognition to be one thing in one employer and another in an alternate employer. 

Also, what if someone straddles professional groups or specialisms and the criteria for recognition in these are different?   What if someone meets all the criteria in one specialism but then moves to another- do they lose the status of ACP? 

Currently there are only a few specialisms that have defined the criteria (or list of competencies) that are required to be an ACP in that specialism.  (e.g. FICM, RCEM and GPN).  As these are very specific to that field of clinical practice, perhaps for those following this prescribed route they would need to add a qualifier to the term ACP such as has been done for ‘Advanced Critical Care Practitioners’.  However, it is possible that someone could meet all of the more general criteria for ACP and be working in this field of specialist practice and yet not meet the criteria for that particular specialist body. 

If these qualifiers for particular specialisms are therefore to be added as a ‘check point’ on the route to be an ACP, a universally agreed list of additional criteria would need to be created.  Otherwise the person may start and end at the right point but will not have picked up a key stamp of recognition along the way.

This is what is referred to as ‘credentialing’.  In the NHS Interim People Plan (page 49) it was noted as an expectation that the use of credentialing would increase.  This would allow more specialisms to have a clearer defined route to recognition of and employment as an ACP. 

However, as we have seen with the Centre for Advancing Practice, work on this appears, not surprisingly, to have stalled with the more pressing matter of a pandemic. 

As noted in my previous posts this risks having a two tier system where some groups of people have a clear and validated route to become an ACP and others not.  This has already created an environment where only those that have a set of credentials to map against and have completed this successfully are seen as ‘real ACPs’.  This of course then leads to inequity for job security, renumeration, career development and feelings of professional value and self-worth.

For me this also creates a nervousness that we are once again getting mixed up between specialist and advanced clinical practice.  Surely the aim here is to recognise someone that is working at an advanced level, not just that they can operate well in a very specific specialism?  Credentialing perhaps places too much emphasis on the clinical competencies and threatens to overshadow the skills needed to work at an advanced level in a range of clinical contexts. 

So where next for ACP?  Perhaps the next step is to think about where it might take someone if they follow the road to become an ACP.  This will the topic of my next blog post.

Advanced Clinical Practitioner education- does previous experience count?

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.

Advanced Clinical Practitioner education Find me the money!

When thinking about the value and impact of ACP education we need to consider how much it costs to train an ACP against the potential benefits it would offer and how this can be funded, otherwise the question will continue to be asked… is it worth it?  There is work still to be done to understand and be assured of the worth of ACP training and education (as covered in some other of my blog posts!).  However, there is also a significant amount of money currently being spent on ACP training and education, and some difficulty in understanding and securing such funding.

The various funding routes for ACP training and education are complex and may often create a barrier for people who may be entirely appropriate for development as an ACP.  My experience is that often individuals have taken quite a while to reach the point where they enquire about the options of ACP training.  Many have expressed this is because they believed the support would not be available for them.  They often are not aware of what the different routes for funding are and may have been ‘put off’ on at least one occasion on route, particularly by their line managers who similarly are unaware of funding routes, and of course do not want to lose a valuable member of staff from the rota during and after the training.

Funding routes for ACP include a much larger range today than may have been present when post-graduate training and education for health professionals began. This is primarily due to changes in national funding schemes where it has shifted from commonly a single source of funding being available, to a larger number of specifically targeted sources of income being provided in this sector.

Ring fencing of funds specifically for ACP training and education through the multi-variate routes has been a growing feature, particularly since the publication of the national Multi-Professional ACP Framework.   However, it is evident that the extent to which ACP is funded, and whether it includes just course fees or salary support and backfill and other expenses is inconsistent nationally. (Council of Deans of Health report on ACP education).

The ACP Apprenticeships, which are the ‘new kids on the block’ when it comes to ACP training, have been seen as a potential answer to this complexity.  This is especially because the largest funder in recent times (Health Education England) has indicated that their operating principle is one of switching off funding when an apprenticeship route becomes available.  Apprenticeships may appear to be a promising proposition to reduce complexity and introduce some consistency.  However, as we have seen already with other apprenticeships in health & social care, they are fraught with difficulties, large administrative burden, and have not achieved the number of people recruited onto apprenticeship schemes that had been hoped.  This has left funds in the apprenticeship levy left languishing unspent despite the demand remaining to be high.  In addition to this, the ACP apprenticeship is at post-graduate level, which is commonly new territory in this field and makes many even more nervous about relying on this to solve the funding supply issue for ACP.

We also need to recognise that some individuals and professional groups are more or less likely to self-fund their CPD training and education. For some professional groups (particularly AHPs) access to funding streams as described above have reportedly been harder to obtain and they have therefore been more likely to self-fund or look for scholarships or charitable organisations to provide funding.  It is feared that if cuts in funding of CPD, as has occurred in the recent past were to continue, whilst some would look to self-fund, many would not be willing or able to do so.  

Whilst the future looks somewhat rosy in this respect due to commitments made in last year’s Spending Round to provide personal budgets for CPD, it’s not at all clear how the problems of the past where funding is available but not spent effectively have now been solved.  Frequently HEIs are not told until late in the academic year what the commissions for such courses are, and often with a time limit of a few months to implement before the funds are no longer available.  Issues of identifying the right staff and getting everything in place to release and support them in time to undertake the training persist and are particularly problematic where staff are in small or specialised teams (more commonly AHPs and more senior or experienced staff).  This makes funding support for ACP largely unplanned and patchy.  This of course then increases the risks on investment in ACP training and education.

As noted in my previous blog, the extent to which ACP programmes, particularly where they have specialist clinical practice components within them, are available does also depend on HEIs being willing to take the risk to invest in developing and delivering the programmes.  They would need to be convinced that

  • They have the staff (with relevant skills and expertise) to work on these programmes, and that there is a secure pipeline of staff to continue to run these programmes.  From the recent work the Council of Deans of Health has done on surveying the landscape of academic staffing, this is a risk and potentially one that is increasing (e.g. due to age of academic staff, and ability to attract and recruit staff from the NHS).
  • There is a sufficiently large market that can be attracted to make the resources spent on delivering it worthwhile.  HEE recently undertook a census to better understand the current supply and demand of ACPs but have not yet shared the outcome from this project.  The ‘ACP market’ is therefore still not well understood.
  • The potential income derived from this activity is at least equivalent to income they could derive from other sources.  The standard tuition fee of £9250 per annum for an undergraduate student acts as a benchmark for this.  Whilst there may be some arguments able to made of ‘other benefits’ that can be gained by running ACP programmes these are commonly measured against the benefits and potentially fewer costs of increasing the number of students on a ‘standard’ undergraduate programme.

All of this creates an unbalanced system where the national framework that defines and sets standards for ACP is ‘multi-professional’, but in reality, only certain professional groups, geographical areas, health care providers or specialist fields of practice can gain funding and thereby recognition, practice and employment as an ACP.  This is an issue that needs to be solved if we to be true to the aspirations of the NHS Long Term Plan and the Multi-Professional Framework for ACP.

Advanced Clinical Practitioner training- generalist or specialist?

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.

What is the value & impact of Advanced Clinical Practitioner Training?

Advanced Clinical Practitioner Training- is it worth it?

“It’s helped me progress in my career and stay in the NHS”, “It gave me recognition for the knowledge and skills I have developed over years of experience”, “It enhances patient satisfaction”, “It improves clinical effectiveness”, “It’s the only way we can maintain a service when we can’t recruit into medical roles”, “It’s a cash cow for the University”. 

These are just some of the proposed benefits that have been pinned to Advanced Clinical Practice (ACP).  We appear to be at a moment in time when there is a clamour for policy, funding and ACP education products in response to what may appear at times to be a panacea for a variety of problems that are trying to be solved in the health care system. 

However do we actually know what the value and impact of ACP training actually is?  Does this vary amongst the key stakeholders (ie the employer/ service provider, the individual health care professional, the education commissioner and the education provider)?

As health care professional educators working within HE we should of course be the first to ask what is the evidence and how can we use this to inform our decision making?  We can point to several studies that provide example of clinical effectiveness in particular specialities using people that have been identified as an Advanced Clinical Practitioner.  Some are able to point to this as adding value to a service rather than just being more cost effective than employing a doctor to do it.  However we also know that just because something has been proven to be clinically effective, it is not always implemented universally or effectively.

For many years reference has been made to ‘Advanced Clinical Practice’ and ‘Advanced Clinical Practitioners’ (or other similar titles).  In 2017, for the first time, a number of professional bodies collaborated with Health Education England to develop the ‘Multi-Professional framework for Advanced Clinical Practice in England’.  This sets out the definition of ACP, the scope of practice and practitioners this applies to, and the standards and capabilities that are expected in order to practice under this title.  Work is also underway, through Health Education England to launch the ‘Academy of Advancing Practice’. 

Whilst this currently falls short of regulation, it has now provided a benchmark or toolkit by which education and training providers can badge their products as leading to advanced clinical practice.  Employers can use this to select individuals to work in ACP roles or undertake what they believe to be ACP related tasks and individuals can provide evidence against the framework to support their credentials as an ACP.

The introduction of this framework, along with additional funding being released specifically for the support of ACP, as well as the development of the Interim NHS people plan which makes specific reference to ACP, the approval of an Apprenticeship route for ACP, and the prospect of potential governance/ regulation through the Academy has led to an increase in activity around ACP. 

Many education providers have undertaken to map their programmes to the framework and promote their courses as ‘ACP’, with some also developing new ACP apprenticeship programmes.  From my experience as a Dean and a CPD programme lead, the release of funding and this being tied to ‘ACP’ has led to an increase in enquiries about the opportunities for ACP training and education.  In response I, like many others have reviewed, refreshed or created new ACP products.

Employers are also now having to review those that currently hold ACP roles or undertake what they believe to be ACP related tasks to ensure they meet the framework expectations.  They have also looked to create new or additional ACP posts in the workforce.  In some cases, this is to provide further career routes and retention opportunities for their highly skilled staff.  This offers the opportunity of ACPs to ‘add value’.  However, potentially for many others, it has also been seen as a way to reconfigure or develop service provision in particular areas, especially where there are shortages of supply of other professionals.  This has led to ACP being seen as purely a way to substitute where Doctors would normally operate (ie we are back to the mini doctor, maxi nurse debate!).  As you can imagine this is creating controversy regarding the actual aim and impact of ACP and nervousness for those that may be working or wanting to work in this field.

Health care professionals are now expected to have longer working lives than ever before.  The fragility of long term careers in a particular service, field of practice or employer has increased with a higher pace of service reconfiguration, development of specialisms and creation of new roles within the field.  This creates a perceived pressure on health professionals to ensure they have the ‘right qualifications’ to allow them to progress in their career or maintain job security. 

So this is a sensitive and potentially explosive topic.  There appears to be a strong belief in the benefits that ACP training can provide and lots of activity happening around ACP education provision.  So this looks like a good moment to evaluate the actual value and impact ACP training has for employers, individual healthcare professionals, commissioners of training and the training providers.  Fortunately it’s also a moment when I am able to start a PhD on the topic!