Multi-professional framework for advanced practice in England (2017)

‘How to ensure the right people, with the right skills, are in the right place at the right time’ is a key priority to enable delivery of sustainable health and care services. This framework is relevant for any service looking to transform its workforce to meet the needs of the population through the employment of advanced clinical practice roles. How these are integrated into service delivery and team structures for a sustainable, consistent approach to the advanced clinical practice workforce development are presented as broad principles. This is so as to embrace the multiple settings and roles at this level and local context. In this section, both planning and governance of this workforce are addressed.

The governance of advanced clinical practice roles is vital to their success. Good governance involves inclusive, participative decision making with clear lines of accountability and responsibility. Policies and processes need to be in place and must include the evaluation of effectiveness, impact, ongoing sustainability and responsiveness. Organisations must ensure that robust governance arrangements surrounding all types and levels of practice, are in place prior to the establishment of new roles, and these must be enhanced and strengthened for existing ones. As stated in the definition at the beginning of this framework, advanced clinical practice refers to a level of practice. Currently many titles are used for health and care professionals who work as this level such as ‘Advanced Clinical Practitioner’, ‘Advanced Nurse Practitioner’ and ‘Advanced Practice Therapeutic Radiographer’. It is important to note that some professionals have been given the term ‘advanced’ in their role descriptor, but may not working at this level for various reasons. This may mean that employers need to review their workforce in order to make sure that there is no misunderstanding by the public and the multidisciplinary team. Where needed, such professionals should be supported, developed and facilitated to work across all four pillars. Governance arrangements must be in place to consider these cases.

In order to embed advanced clinical practice and ensure its sustainability, it is necessary that the organisational governance and infrastructure arrangements include consideration of the following aspects of service transition:

• Practice governance and service user safety requirements
• Adherence to legal and regulatory frameworks
• Support systems and infrastructure for delegated roles (e.g. requesting diagnostic tests, administering medicines)
• Professional and managerial pathways of accountability
• Continued assessment against, and progression through, the capabilities identified within this framework
• Location of advanced clinical practice within a career framework that supports recruitment and retention, and succession planning to support workforce development
• Regular constructive clinical supervision that enables reflective practice together with robust annual appraisal.

The process of planning and thinking through these elements for advanced clinical practice roles in the workforce should result in the development of a business case that includes the above information and the resources required. The financial aspects should not be considered in isolation. Consideration must also be given to the ongoing support and structures that may be required to facilitate education, ongoing development, assessment and supervision (see the Education and development section). A risk analysis and options appraisal, as well as an evaluation of the impact and effectiveness of existing and new roles should be included

In identifying the need for such roles and their potential impact, employers need to:

1. Consider where advanced clinical practice roles can best be placed within health and care pathways to maximise their impact
   Historically there have been many drivers for the introduction of the level of advanced clinical practice: clinical, operational, financial and professional. However, primary consideration must be given to where this level of practice would be best placed for greatest impact in health and care pathways.
   This may mean that those working in advanced clinical practice might operate outside traditional service delivery boundaries and potentially, traditional professional boundaries. The intention should be to move towards developing and planning the workforce to meet local population needs. Therefore, at the local area level, organisations should be working to generate a sustainable supply of health and care workforces who are able to work more flexibly across these boundaries.
2. Define a clear purpose and objectives for advanced clinical practice roles
   The level of advanced clinical practice typically exists across professional boundaries within multi-professional teams. Planning must not be done in isolation, local consideration must be given to workforce supply, existing roles and support for development. In addition, attention must be paid to the starting points for different professions relative to their core training, as well as to their duties and responsibilities. The capabilities which reflect the area of work or specialty will be required to be clearly defined.
   Clinicians and service managers should be involved in planning the workforce together. Such planning should focus on the wider team, thinking about the value of the role and its purpose and objectives. Practitioners must be working to national standards, where these exist.
3. Consider and evaluate the impact of advanced clinical practice roles on service user experience and outcomes and on service delivery and improvement objectives
   Patient/service user and public involvement in understanding these roles, their functions and boundaries as part of the wider health and care teams, is essential and must be built into this process.
   The importance of ensuring continuous improvement in the quality of care to individuals is widely recognised. It is therefore necessary to measure the impact of the activities of all staff, with a particular focus on new roles added to the workforce. The development and utilisation of robust evaluation methods is essential. In addition, evidence demonstrating value for money and good quality of care may be required to influence senior management teams to support the introduction of new roles. This will include how the organisation or employer should quality assure itself to ensure the safety and effectiveness of the advanced clinical practice roles. For example, by using methods for monitoring and evaluating both effectiveness and impact such as, the monitoring of complaints, incidents and patient/service user outcomes and feedback. This is an essential part of governance, i.e. the observation and evaluation of intended and unintended consequences.
   There are specific questions employers need to address in considering advanced clinical practice roles and to ensure good governance of those roles
   • What objective outcomes are expected from the advanced clinical practice role?
   • When will these outcomes be achieved and how will these be measured pre and post implementation?
   • What risks and unintended consequences might there be to the introduction of this role and how may they be mitigated against?
   • What resources and support are required for role development and succession planning?
   • Is workforce optimised to ensure clinical and financial benefits are maximised?
   • How will on-going competence and capability be reviewed and enabled?
   • What reporting and line management structure will be in place?
   • What processes will identify gaps in performance and/ or shortfalls in implementation and how will these be addressed?
   • Has a quality assurance model been considered to measure this e.g. CQC 5 key lines of enquiry which will support inspection.
   Thinking through these questions and finding answers will then guide governance structures and policy development but also evaluation against expected and unexpected outcomes.
4. Ensure clarity about the service area the individuals will work within
   Understanding the level of advanced clinical practice relative to the wider team, requires the roles of all team members, i.e. those above, below and surrounding this level, to be understood. Multi-professional engagement in this work is essential to build trust, understanding, supervision and support (see the ‘Education and development section’ for more information on supervision). Those working in an advanced clinical practice role will need to negotiate their individual scope of practice with service managers and the rest of the team. The wider team needs to understand the level of accountability of those in this role. To achieve these objectives there needs to be clarity and understanding as well as a proactive culture of working in partnership.
   By advancing the level of practice of some staff, the people in the grades below may need some development to increase their skills and knowledge as the expectation of their roles develops too. Staff in the grades above may need some support to potentially change some aspects of their role and potentially start doing some work differently. This must be understood, supported and widely communicated.
   Employers also need to consider impact planning and the evaluation of the team into which the new role is introduced, and those it may impact on outside this team, reflecting on the implications for the skills mix and any changes that might be needed.
   This process may then enable career and succession planning opportunities.
5. Ensure clear and unambiguous support for the role from the organisation/ employer at all levels
   The employer must recognise the responsibilities and capabilities of someone working in these roles. This must be reflected and supported at a local and organisational level. The support must be wider than educational, the voice of the those working in an advanced clinical practice role must be heard via existing or new governance and reporting structures. The board level directors, the clinical leads for the profession and managers must be aware of, understand and recognise the value of, advanced clinical practice roles. This must be cited in the governance arrangements, so that there are clear lines of professional and managerial accountability up to board level.
   In addition, the employer must be aware that certain skills, e.g. prescribing, are only legally allowed for certain professions, and that this does not preclude all professions from working in an advanced clinical practice role.
6. Develop a succession plan for future workforce
   This should be actively supported for service sustainability, succession planning and staff retention. Clarity in the above principles will enable a clear pipeline to be developed and will support retention.

Health and care professionals working in advanced clinical practice roles are encouraged to work to their full potential to optimise the benefits that can be gained from new models of care. Therefore, individual and organisational governance need to be robust and within legal, regulatory and professional frameworks, as there is a possibility that professionals taking on new roles and responsibilities could put people at risk. This could be caused by lack of competence to carry out duties safely or effectively, or where adequate safeguards are not in place, if these roles are not properly supported. This section examines these elements of governance which must be in place for the advanced clinical practice role. 

For the purpose of this document and the point in time at which it has been formulated, this framework applies to those who have statutory registration. In order to offer clarity to the system, this work has been formulated with the regulated workforce in in mind. It is understood that there are some professions that are being considered for statutory regulation and therefore are not registered at this time. Not being registered does not preclude these professional groups from working at this level but employers and employees must understand the implications and have an appropriate approach to this through safe and effective governance.

The development of advanced clinical practice roles requires that:

1. Individual practitioners, as registered professionals, continue to hold professional responsibility and accountability for their practice.
   Work by the Commission for Healthcare Regulatory Excellence (2009), now the Professional Standards Authority, emphasised that the activities undertaken by professionals at a level of advanced clinical practice do not lie beyond the scope of existing regulation, unless the nature of their practice changes to such a significant extent that their sphere of practice is fundamentally different from that at initial registration.
   Practitioners working in advanced clinical practice roles must be aware of their own limitations and through this, recognise the parameters of their scope of practice.
   It is proposed that advanced clinical practice roles should reflect a set of responsibilities and capabilities which act as an indicator of a specific stage on the career development ladder. In addition, such practitioners will always be accountable to their original regulatory body, whatever the level or context of their practice. This has been reflected in the capabilities.
2. Employers recognise and accept potential new responsibilities and greater accountability in relation to governance and support for these roles and associated level of practice.
   Governance has been mentioned in the key principles for planning the workforce and governance. It is also cited in the capabilities. It applies to all registrants and is articulated within respective professional codes of practice. Employers carry responsibility and vicarious liability for practitioners, and must be responsible for ensuring that all advanced clinical practice roles, both those that are existing or those of the future, do not compromise safety. Policies and processes may need to be modified to reflect this. Without this, there is a risk of “unconscious incompetencexii”, which may compromise safe person-centred care, as well as the reputation of advanced clinical practice.
3. Professional support arrangements, which recognise the nature of the role and the responsibilities involved must be explicit and developed.
   Good governance regarding new role development and implementation must be based on consistent expectations and understanding of the level of practice required to deliver the service and assure safe quality standards of practice for service users. This is best achieved through the benchmarking of such posts against: agreed standards in England, best practice and the capabilities under the four pillars. Strategies such as supervision, mentorship, good record-keeping, ongoing self-assessment and development are an essential element of demonstrating accountability within practice. Existing professional support mechanisms may not be sufficient and may need to be reviewed.
   These processes and strategies should be complemented by clear lines of professional responsibility and linemanagement and regular independent clinical reviews. Management lines of accountability may need strengthening as often staff will have a line manager separate to their team and may perhaps work across a number of teams which may add complexity and competing pressures. This must be understood and managed.
   Appraisal processes may need strengthening. These processes will need to be completed in collaboration with the line manager and an appropriately qualified clinical lead. Appraisal may use evidence or feedback; clinical audit data; outcomes and issues review: productivity measures; 360 degree feedback and service user feedback.
   This approach provides the most effective means of controlling risks to a patient/service user’s safety from an individual professional’s practice and provides a proportionate response.
4. Employers must ensure regular review and supervision is carried out by those who are appropriately qualified to do so.
   Governance arrangements must also ensure that those who support and review practice are also developed, facilitated and supported to carry out this role.

This section outlines the principles to support the development of the workforce to work at the level of advanced clinical practice. The document recognises and respects that there are many ways to gain and develop these capabilities. It aims to ensure that there are robust and clear routes to evidencing achievement of the capabilities. Educators and employers are therefore challenged to enable capability and competence, offering an environment and a process that allows practitioners to develop abilities that are sustainable for changability, improvability and responsiveness.

At an advanced clinical practice level the attainment of both competence and capability are important:

• It is essential that practitioners are developed to be clinically competent within their specialty, sector and setting.
• Capability development is also essential: this requires practitioners to be able to recognise what level of competence is required within any given situation and apply this successfully, recognising the limits of their competence. Capability also requires the practitioner to have the ability to extend these limits when required and flexibly adapt to unfamiliar professional environments.

Local adaptation of this guidance is important to ensure workforce development is matched to local population needs, however the capabilities are deliberately stated in order to support a common understanding and expectation of this level of practice, in order to facilitate the development and mobility of this workforce at scale.

In order to meet the diverse and ever-changing workforce needs, it is essential that an outcome driven approach

to developing the workforce is utilised, using the capabilities to ensure underpinning consistency and rigor. Therefore, the focus must be on the outcome, i.e. of the capabilities being met at the required level, as opposed to the developmental input or the educational process undertaken.

Education progression routes need to enable practitioners to develop and demonstrate the capabilities, recognising that this can be achieved in multiple ways, dependent upon sector, profession, setting, role and service need.

The flow chart in the ‘Development routes’ diagram (page 16-17) shows the educational routes possible to develop both clinical competence and capability.

The development of health and care professionals to enable them to operate at the level of advanced clinical practice, requires three elements within the workplace:

• development of competence and capability
• supervision and support in the work place
• assessment of competence and capability

Practitioners and employers will need to work collaboratively to identify individual learning needs and determine the most effective route to meet these. It is essential to recognise that each profession will begin from a different starting point in their development of advanced level skills. Employers are encouraged to support practitioners to identify personal learning plans, help and meet their learning needs by supporting the:

• clear articulation of the role and scope to be undertaken
• understanding of the availability of existing speciality specific national clinical competencies or support to develop these with the clinical team
• mapping of previous education or experience against the four pillars to decide whether a practitioner’s existing qualifications cover the relevant capabilities required for the level of advanced clinical practice in the health and care professional’s setting, subject area and job role. This may enable the individual to evidence some of the required capabilities through a portfolio route or as APL/APEL
• appraisal of existing educational programmes content, approach and structure to determine match to individual requirements
• agreement of an appropriate educational approach e.g. programme of assessed work based learning and/or an academic programme
• understanding of funding routes e.g. apprenticeship, local funding arrangement etc.
• agreement of the required work based assessments to evidence sustained attainment of the agreed capabilities in practice
• support of a named, trained educational supervisor, who is a specialist within the clinical area, to support the work based learning and
  assessment and sign off for the capabilities/portfolio.

The accreditation or recognition of relevant prior learning or prior experiential learning (APL/APEL) process is integral to ensure health and
care professionals’ existing qualifications and experiential learning are recognised as appropriate.
New models of evidencing RPL and equivalence are being explored.
Individuals and healthcare providers may utilise a combination of approaches e.g. work based learning, simulation or e-learning to ensure that professionals developing a portfolio to evidence advanced clinical practice get full exposure to the appropriate levels of learning. All routes are important as some health and care professionals aspiring to work in an advanced clinical practice role may have completed alternative qualifications at master’s level, particularly in health and care professions that require a master’s level award for registration.
Clinical training must acknowledge the importance of time and experience to build confidence in decision making and the management of risk.
It is important to note that having a master’s degree does not grant the practitioner advanced clinical practitioner status. Evidenced achievement of the capabilities, employer support and a clear funded role to move into are all essential components.

Individuals will need to commit to the achievement of the assessment requirements for the level of advanced clinical practice, however, they will also be reliant on the support of others.
During their development individuals will require the support of an identified educational supervisor in the work place, for example a colleague working at consultant level or another appropriately qualified senior practitioner. The supervisor will provide continuity of support and an overview of the development of the individual practitioner as a whole.
Other staff may undertake supervision for shorter, focused periods of training. The supervisor and members of the wider education teams will need to be clear about the roles and responsibilities each has for day-to-day support in developing individuals, as well as being aware
of their importance in nurturing and supporting the personal development of individuals.
Access to supported peer review, in addition to a supportive environment is essential and may happen within or across organisations. The use of action learning sets or learning groups offers a broader level of support.
Professionals working at a level of advanced clinical practice have a responsibility for their on-going continuing professional development. Employers will need to ensure there are opportunities for continuing professional development to ensure patient safety, the appropriate ongoing development and maintenance of capability.

A key element of the preparation for individuals to practice at the level of advanced clinical practice will be a formal assessment of achievement of the capabilities, specific to the context of their practice. It is critical to the implementation, acceptance and sustainability
of advanced clinical practice that health and care professionals working at this level are widely recognised as having a consistent level of competence. They must also be equally capable of fulfilling the specialist requirements of functioning at this level.

Assessment outside of formal programmes of study will need to be valid and reliable and may include: case based presentation, theoretical and/or practical tests of knowledge skills and behaviours critical reflections, portfolio of evidence etc.

To ensure assessment in the workplace is valid and reliable:

• assessors must be occupationally competent, recognised as such by employers and education providers, and be familiar with the chosen assessment tool
• a range of assessors, trained in the relevant assessments, should be used, including educators with appropriate academic and clinical experience and competent health and care professionals at the required level
• healthcare providers must invest in and support staff to undertake assessment(s) in practice.

Work based assessment must happen within the work setting undertaken by experienced clinicians aware of the benchmark level of capability required for this level of practice, especially where a variety of professions are undertaking advanced practice skills.

There will be a strong need for collaboration and working across professional and organisational boundaries to ensure that learning and assessment in practice delivers practitioners who consistently meet the required outcomes in all settings.

This requires experts trained in the standardised assessment of The Framework for Higher Education Qualification – QAA level 7 work based learning to review the collected portfolio of evidence submitted against the capabilities listed. This should be undertaken by a balanced group of two or more experienced assessors and an agreement reached if the panel agree that the portfolio of evidence reflects the registrants’ assertion that they have met the standards.

Local arrangements are recommended and should be resourced locally, enabling local partnerships with experienced and trained clinicians, postgraduate medical educators, Higher Education Institute (HEI) staff or as part of a Royal College/Professional Body accreditation programme.

In order to optimise cost effective training, collaboration across an area or place may be required to enable master’s level programmes offering sufficient flexibility to develop the workforce to have the required speciality specific competency and broad capability across the  four pillars. The specialist modules may need to be delivered across England, regionally or locally due to numbers of learners required for course viability. Thus, APEL/APL and flexible work based learning are vital to enable this to be accommodated within local programmes of study.

The development of bespoke local support with practice educators/educational supervisors, Higher Education Institutes and/or Postgraduate Medical Education will offer useful local momentum to support this work, for example: a collaborative programme to appraise portfolios utilising existing clinical experts and educators within service work based units to ensure meaningful clinical exposure and assessment specialist training modules adoption of national specialist clinical standards into programmes, where they exist delivery of inter-professional learning and support where feasible, to support workforce transformation, by building relationships, trust and respect workplace assessment.

The potential offered by the apprenticeship route at level 7 will need to be understood and explored, as one of a number of potential vehicles to support the delivery of this agenda. This work has been developed alongside the apprenticeship standards and both documents support the development of the workforce to the same level and capabilities, although the language used has needed to be different. It has been necessary to set the Apprenticeship level as full master’s award due  to the nature of the process, this document offers further flexibility to service to support a variety of outcome focused developmental routes to build workforce capability.