In this blog RCEM Vice President, Lisa Munro-Davies looks at the history of Advanced Clinical Practice, the latest national developments, and what the future might hold.

What is Advanced Clinical Practice (ACP)?

Advanced clinical practice (ACP) is a defined level of practice within a range of regulated clinical professions such as nursing, pharmacy, paramedicine, occupational therapy and all 12 other of the 14 Allied Healthcare professions (AHP). This level of practice is designed to transform and modernise pathways of care, enabling the safe and effective sharing of skills across traditional professional boundaries. 

Advanced clinical practice is delivered by experienced, registered health and care practitioners. It is a level of practice characterised by a high degree of autonomy and complex decision making. This is underpinned by a master’s level award or equivalent that encompasses the four pillars of clinical practice, leadership and management, education and research, with demonstration of core capabilities in an area of specific clinical competence.

Advanced clinical practice embodies the ability to manage clinical care in partnership with individuals, families and carers. It includes the analysis and synthesis of complex problems across a range of settings, enabling innovative solutions to enhance people’s experience and improve outcomes.

Is Advanced Clinical Practice a New Concept?

The origins of ACP in nursing can be traced back as far as the 1960’s in USA and Canada. Development in the UK began in the 1970’s and in Australia and New Zealand in the 1980’s with extension of the concept into AHP roles being a more recent inclusion in the late 1990’s/2000’s.

Is there a single quality assurance standard in ACP training and who regulates ACPs?

Although ACP has existed in the UK for many years and ACP roles have grown in that time the UK lacks a single regulatory framework to define advanced practice and the education required to underpin it. This has led to confusion to date as to what ACP comprises and has implications for patient safety as well as having been a limiter on the integration of the role into future workforce planning. It has also led to a variety of titles being applied across roles e.g. Advanced Nurse Practitioner/Advanced Practitioner/ Advanced Clinical Practitioner / Advanced Critical Care Practitioner sometimes creating further confusion as to what each title has in common or not in terms of skills, abilities and level of practice.

Health has been a devolved responsibility in the UK since the 1990’s with each country having its own defined National Health Service (England, Scotland, Wales & N Ireland).

All four nations have developed frameworks for advanced practice. NHS Scotland was the first and published it’s ACP Framework in 2008. There are many commonalities between all four Frameworks which should help ensure patients, professionals and healthcare providers benefit from the potential contribution of ACP. But, these Frameworks themselves are not yet fully harmonised and regulation for all remains the responsibility of the practitioners initial professional registration of NMC or HCPC.

 As such, there is little professional or regulatory accountability specifically directed at ACP. The term ‘Advanced Clinical Practitioner’ remains an unprotected title which continues to be liberally and varyingly applied in both employment and educational settings. The variance in performance and skills amongst practitioners who have the same job title applied to their clinical working that this has created has been a significant inhibitor to establishing universal professional and public confidence in these roles to date. In the absence of a single quality assurance standard in training, practice and regulation this will likely continue.

It was in part to address these issues that in 2015 the Royal College of Emergency Medicine (RCEM), and the Faculty of Intensive Care Medicine (FICM) launched curricula and credentialling processes for Emergency Care ACPs (EC ACP) and Advanced Critical Care Practitioners (ACCP) respectively with the aim of providing a consistent standard in training and education for ACPs working in Emergency Departments and Intensive Care Units.

Subsequent to this in 2017, Health Education England (HEE) published a Multi-professional Framework for Advanced Clinical Practice for England providing a basis to align existing educational curricula and competence frameworks with the aim of creating greater consistency across advanced clinical practice as well as to inform further future developments for ACP careers.

The HEE ACP framework applies specifically to England, but has been developed in consultation with stakeholders that represent professions across the UK (e.g. Professional Bodies and Royal Colleges including RCEM) and has drawn on similar advanced practice frameworks that exist in the other three countries.

All these developments further reflect the need to establish quality assured training and career pathways for ACPs that protect both patients and the professionals.

Has Advanced Practice resulted from medical workforce shortages and is this just medical substitution?

There is no doubt that medical workforce shortages have been one of many catalysts fuelling review and reappraisal of traditional roles and responsibilities amongst the healthcare workforce. However, it would be wrong to interpret this as the sole or even dominant driver in the development of Advanced Practice in many countries including the UK.

Advanced practice had not been part of NHS strategic workforce plan until very recently and, much that has developed over the decades already has evolved to better meet the needs of specific patient populations. As numbers of ACPs have increased in these and other areas the benefits of the inclusion of ACP in the multidisciplinary workforce has been increasingly recognised and the evidence base supporting the benefits in terms of safety, quality, efficiency and patient experience is ever increasing.

The misconception that ACP development is driven by medical workforce deficits is fuelled by many complex cultural factors historically ingrained in much of the healthcare workforce. These are broadly based on concepts of hierarchies in: clinical technical skills, the value of such skills and status and power inferred by these. The status and power differentiation between groups being implied by nomenclature such as ‘medical’ vs ‘non medical professionals’.  

So, despite Medical workforce shortages and containment of workforce costs being oft cited ‘chief drivers’ by sceptics of ACP development, and although not totally irrelevant these have actually been demonstrated to be minor factors in promoting such change.  The greatest drivers identified are in fact: changing patient needs, greater access to services, quality & continuity in care and career progression for nursing and AHP professions.

The assertion that medical substitution is a chief aim of ACP development is again equally limited.  Such a blunt approach fails to adequately consider the complex landscape of: increasing healthcare demand, increasing case complexity and the ever evolving evidence base that safety and quality enhancements in care are best delivered by a matrix of clinical professionals working as an integrated Multi-disciplinary team (MDT) wherein patient need is the primary driver and historical hierarchies do not dictate boundaries of working nor roles.

All members of such MDTs bring different, complementary skills, knowledge and attributes which when seamlessly blended deliver enhancements in patient care and experience. Another important factor is that ACPs tend to have long term careers within their areas of clinical practice so providing a consistence and continuity in care that is absent from the rotational nature of medical workforce training. In turn such an experienced, stable core workforce can enhance the educational opportunities and training for any and all trainees that may rotate through such an environment. This is again in direct challenge to another oft cited negative assertion that ACPs dilute the training opportunities for medical rotational trainees. With an established ACP workforce within a clinical team the reverse is actually the truth and experienced ACPs are able to deliver training and supervision to lesser experienced clinical trainees across the MDT so increasing trainer numbers due to enhanced levels of experienced clinicians within a team.

What is the Future for Advanced Practice?

The potential for ACPs to be a significant element in addressing the very real issues and shortages we face in the workforce of all UK 4 Nations Health Services is now clearly appreciated.

The opportunity to transform pathways of care through the inclusion of ACPs in MDTs as well as the improved recruitment and retention of nursing and AHP professionals by providing clear, supported training and career pathways are all important elements to this.

Expansion in Advanced Practice provision is integral to meeting the aspirations of the NHSE Long Term Plan in England as an example of this recognition. The establishment in 2020 of the HEE Centre for Advancing Practice has been a significant financial commitment to this direction of travel in England. The Centre and it’s Regional Faculties provide co-ordinated funding, support and development for single standard, quality assured AP careers across all professions and scopes of practice from beginning to end with a portfolio of development  including: initial AP training programmes, a National digital badge system for recognition of level of training attainment and development of guidance in governance to support ACP working, CPD and career progression for ACPs from accreditation to the level of non-medical consultant working.

Whilst this is an England based development there continues to be ongoing discussions and exchange of learning across all 4 Nations and the benefits of a single quality assured standard and a unified regulatory framework for ACP are acknowledged.

RCEM remains committed to supporting the future development of our EC ACP workforce and is rightly proud of the proactive approach taken in 2015 to develop and offer the existing credentialling process as a clear and consistent quality assurance standard in training and practice for EC ACP.

This commitment is further demonstrated by the establishment of our ACP Forum and its role in RCEM since including supporting the current revision of the original EC ACP curriculum to be launched in September 2022, ensuring our training remains current and fit for purpose as the educational landscape further evolves in all clinical practice.

RCEM also continues to work with the Health Service in all 4 Nations to ensure that the ongoing wider developments in training and onward ACP careers remain aligned to and accessible by our EC ACPs at all levels and stages of their careers.  

Key Points

• Advanced Practice has been in development in the UK for over 50 years.
• In contrast to some other countries the UK lacks a single unified regulatory approach to Advanced Practice which creates variance and risk.
• All 4 Nations have developed ACP Frameworks and there is much that would be gained by establishing an agreed single quality assurance standard in ACP across all.
• The chief drivers in ACP development are: changing patient needs, greater access to services, quality & continuity in care and career progression for nursing and AHP professions.
• ACP can be wrongly labelled as medical substitution which fails to recognise the real drivers and the complexity of our healthcare landscape as well as the many benefits realised from the roles.
• Numbers of UK ACPs continues to grow with a now increased drive for expansion in all Health Services to realise the proven benefits in patient care and workforce they deliver.
• RCEM remains committed to the future support and development of our EC ACP workforce at all levels of their careers and to ensuring this remains aligned to wider ACP developments in all 4 Nations.