Healthcare in the UK has changed significantly over the last few years, with increasing pressure as a result of higher demand, greater workloads and widespread financial constraints (NHS England, 2014; 2017). At regional and local levels, there are widespread recruitment and retention issues, which have resulted in significant workforce gaps. The advanced nurse practitioner (ANP) role has increasingly been implemented to bridge the gap in services and has more recently extended to include other health professionals, including paramedics (Mahtani et al, 2018; NHS England, 2018). Historically, advanced practice is an umbrella term that refers to a level of practice in a range of clinical roles (Currie, 2010), which have lacked consistency in scope of practice, training and regulation (King et al, 2017). The growth of these roles has been accompanied by the debate about how these roles should be defined and what core capabilities and skills are required, because in theory anyone can call themselves an ‘advanced practitioner’ (AP) as the title has no protection (Nadaf, 2018).
In direct response to the NHS 5 year forward view (2014), for the first time ever Health Education England ([HEE], 2017a) has published a multi-professional framework, which sets out an agreed definition for advanced clinical practice. It identifies the clinical and educational standards expected of clinicians working at advanced levels, across the four pillars of clinical practice:
- Clinical practice
- Education
- Leadership
- Management and research.
HEE aim to implement these standards by 2020 (HEE, 2017a), and so it is pertinent to consider the capabilities and educational levels of practitioners currently working at this level, so that advanced workforce planning can ensure the quality and safety concerns identified by documents such as the Francis Report (2013) are addressed.
Aim
The aim of this study was to identify what an advanced practice role currently means in primary care in Cornwall. It looks at experience, scope of practice, educational level of clinicians, and whether those roles are graded in line with skills and education.
Methodology
Design
An electronic questionnaire was sent to all clinicians who were identified by their practice website as working at an advanced level or with an advanced title. The questionnaire included questions about professional registration, length of time in current role, educational pathways and qualifications achieved. Participants were asked about the types of clinical presentation they saw in their practice, including what investigations they requested and/or interpreted, and what hourly rate of pay they received for undertaking this role. The data collected were anonymous and all questions were optional.
Ethical consideration
Ethical approval was obtained from the University Of Western England's internal ethics committee. Written information was supplied to the participants, and participation was voluntary and anonymous. Participants were also given the opportunity to request the results of the completed study.
Sample
Cornwall has 61 GP practices. Not all employ advanced clinicians; some employ several. Although a variation of nursing roles exists in primary care, with titles and a scope of practice greater than that of the traditional practice nurse, it was decided to only include nurses who work with a title which implied advanced practice. Paramedics have recently been employed in general practice, in new and extended roles, and so all primary care paramedics were included in the study. A total of 57 advanced clinicians were identified from practice websites and so these became the target group. From the questionnaires sent, 34 respondents took part, which gave a response rate of almost 60%.
Results
It quickly became evident that the majority of clinicians currently working in advanced primary care roles in Cornwall are nurses, with only 17.65% (6) being paramedics. Twelve different role titles were identified in this small sample, which is consistent with the findings of Leary et al (2017), who identified 595 different titles within specialist nursing practice. Advanced nurse practitioner, nurse practitioner, specialist or practice paramedic and emergency care practitioner were the most common in Cornwall.
Clinicians undertaking advanced roles all had significant clinical experience, with the length of time qualified ranging from 15–43 years, and with little difference between nurses and paramedics in terms of clinical experience years. Time in post averaged at 3 years, but some clinicians had been in their advanced role for 18–20 years.
Education
In total, 45% of the respondents in this study had undertaken masters' level study, with only 23% of those having achieved a full MSc (see Figure 1). Of the respondents, 3% had a PGCert and 19% a PGDip, with one respondent having achieved a PhD. Two clinicians did not have a degree, and eleven (32%) had not studied beyond degree level. Of those who held a degree, several had achieved a specific nurse practitioner or emergency care qualification, while others had a degree in adult nursing or health studies.
Figure 1. What is the highest level of qualification you have achieved?
One common theme was that all the nurses were independent prescribers, which seems to be an agreed requirement for advanced practice for nurses.
Scope of practice
Participants were asked which clinical presentations they see in their day-to-day practice and were given a list of 17 categories commonly presenting in primary care (Figure 2). There was no opportunity to be specific about the clinician's level of competence or confidence within a category, which is recognised as a limitation of this study, but it was possible to get a broad idea of which patients fell within the remit of each AP.
Figure 2. Clinical presentations seen in day-to-day practice. ENT, ear nose and throat; HRT, hormone replacement therapy
All but one respondent consulted with patients who present with musculoskeletal (MSK), respiratory or abdominal problems, and only two clinicians stated that they do not see ear, nose and throat (ENT) or paediatric (over 5 years) patients as part of their remit. Almost half the participants stated that they do not see patients for hormone replacement therapy (HRT) and a quarter do not undertake mental health, gynaecology or family planning consultations.
The Royal College of Nursing (RCN) (2012) advises that independent nurse prescribers should only treat pregnant women for non-pregnancy related minor injury or illness, and 79% of participants said they routinely see and treat pregnant women on this basis. The Nursing and Midwifery Council (NMC) have no specific guidance in this area.
Investigations and referrals
Only one participant stated that they do not make referrals on to secondary care. Twenty-seven clinicians (79%) request X-rays and just over half of them interpret the results, while around 60% interpret blood results, although it was unclear how broad a range of results this included. One participant stated that they do not request any further investigations; it was noted that this was not the same clinician who does not make secondary care referrals.
Remuneration
Of the 34 APs who took part in this local study, all but one disclosed their hourly rate, which revealed significant disparities, varying from £15 per hour (Band 6) to £31+ (band 8c).
One practitioner, earning £15 per hour, was not a prescriber and had no degree level qualifications. They did not disclose how long they had been registered in their profession, but had been in post a year and ticked all 17 clinical presentations as being within their scope of practice. They confirmed that they make independent secondary care referrals and request and interpret blood results and order X-rays. Their role title was ‘Practice Paramedic’. A second practitioner, earning £20 per hour, had no degree qualification, but was an independent prescriber. Their title was Practice Nurse Manager and they also ticked all 17 medical presentations as within their remit. They also make independent referrals to secondary care, request and interpret blood results and order X-rays. It would appear that while neither of these clinicians carry an advanced title, both encompass the competencies and skills identified within an advanced practice framework, which require a greater level of education and accreditation of the four pillars of clinical practice to meet with the required standards (HEE, 2017a).
Thirteen participants (38%) had not entered a masters' programme of study, but had achieved honours degrees. Of these, their pay ranged from £18 to £30 per hour. The lowest paid clinician in this group ticked only 7 of the 17 medical presentations and did not interpret any results, although did request investigations and made independent secondary care referrals. They had been in post 12 months but had 26 years of nursing experience. At the other end of the spectrum, two degree educated nurses, paid £30 per hour had been in post 20 years each and included 15 and 16 medical presentations in their daily clinics. Both made secondary care referrals and were autonomous in their requesting and interpretation of further tests.
The remaining degree-educated practitioners were paid an average of £25 per hour and there appeared little correlation between their hourly rates and length of time in post, experience or scope of practice; some saw less presentations and were paid more, while others fulfilled all areas of the role and were paid less. HRT, family planning and gynaecology were the most common presentations not undertaken.
Eleven clinicians were currently on the masters' pathway, with the majority of them seeing 12 or more of the medical presentations listed. One clinician only saw three presentations (MSK, ophthalmology and minor injury) from the list and did not request or interpret bloods but was only paid £18 per hour, while the most highly paid in this group was paid £27 per hour; a clinician who requests and interprets bloods and x-rays and ticked everything but HRT and pregnant women. The remaining clinicians' pay ranged from £19–£26 per hour with little consistency between length of time qualified or time in post.
This study identified that only 7 of participants had achieved a masters' degree, one of which was in healthcare, with the others in advanced clinical practice. One had achieved a PhD, which meant that 8 ANPs met the full HEE standard for advanced practice. Six practitioners in this group saw all 17 medical presentations, while the others saw 14. All except one request and interpret investigations and all were nurses. The range in pay for this group was between £22 and £31+ per hour, with the average being £26. The two clinicians at the upper end of the scale had been in post for 18 years and 3 years, respectively, which again indicates that there is no correlation between time qualified or length of time in post and level of pay.
‘Until now, there has been a slow movement towards the uptake of credentialing from clinicians currently in post, and additionally there is poor understanding of standards from employers who are often in desperate need of clinicians to fill roles.‘
On the whole, although not exclusively, paramedics were paid less than the nurses, although one paramedic was paid at £25 per hour, with no Masters' study and no prescribing. This trend may change as prescribing evolves within this group and more paramedics move into primary care.
Discussion
Many countries require national regulation of advanced practice titles, although there is variation in how this is achieved (Pulcini et al, 2010). In exploring regulation of these roles internationally, Maier (2015) and Heale and Reick Buckley (2015) identified challenges in professional body regulation, government regulation, and local regulation by employers. The lack of standardisation and regulation for advanced practice has meant that the role has developed opportunistically and has added to the wide discrepancy in role title and clinical practice (King et al, 2017).
The RCN (2016) and HEE (2017a) identified that advanced clinical practice needs to be underpinned by masters' level education, but the reality in practice is often very different. In total, 45% of participants in this study had studied at masters' level with only 26% completing, which is consistent with the findings of Gerrish et al (2011) who found that less than one third of ANPs in the UK held a masters' degree.
While all the nurses were independent prescribers, historically paramedics have been excluded from non-medical prescribing and so their autonomy has been limited to patient group directive prescribing, which can potentially be constraining. Now that the opportunity to achieve the non-medical prescribing qualification has been extended to paramedics who are following a masters' pathway and working in primary care at an advanced level (College of Paramedics, 2018), it is likely that this part of the primary care advanced practice picture will change in the coming years.
The broad definition of advanced clinical practice means that many different roles fit within the advanced practice umbrella, and while many clinicians' practice within a narrow or specialist framework, APs within primary care often work with a much higher degree of risk, and many of their additional responsibilities fall under the auspices of medicine (Brook and Rushworth, 2011). This study sought to identify whether clinicians in Cornwall are working with a broad spectrum of skills and whether the scope of practice is consistent with levels of experience and education.
The introduction of Agenda for Change (AfC) in 2004 meant a significant pay increase for most nurses, with the potential for annual incremental pay increases and the chance to progress through pay bands with the appropriate education and acquisition of further responsibilities. The majority of GP surgeries did not adopt the AfC pay banding (Department of Health, 2004), and so, consequently, most primary care staff have to negotiate terms and conditions of employment on an individual basis (Ashwood et al, 2018). This said, AfC is the only benchmark that nurses in primary care have when comparing roles to grading or pay. Additionally, there is no definitive national documentation setting out the recommended banding or pay scale for an advanced clinical practice role in either primary or secondary care, although there are numerous regional references to a trainee role being equivalent to band 7 and upon completion of a full MSc, Band 8a and above (RCN, 2012; HEE, 2015; 2017b; Lambeth CCG, 2017).
The significant inconsistency in pay at this level is highlighted by the findings of Fawdon and Adams (2013) and Marsden et al (2013), and it could be said that this is the legacy of a role which has no regulation or, until recently, framework. It might be argued that such a wide disparity in pay is indicative of an evolving role, with varying levels of experience and education, but there was little evidence of pay being consistent with either of these measures in this study.
Conclusion
The Council for Healthcare Regulatory Excellence (2009) states that advanced practice is a dynamic process which evolves along a continuum. This continuum is evident in this small local study where clinicians are undertaking roles which require greater clinical accountability, underpinned by autonomous critical thinking, complex reasoning, research, analysis and reflection (the four pillars). The range of knowledge and experience and scope of practice is enormously varied, as is the recognition afforded the role in terms of status, credibility and financial reward, which brings us back to the argument for regulation and registration of the advanced role.
The debate, which is decades old, has gathered momentum in recent years as the role has expanded. Quick et al (2015) felt that clarity of advanced role titles, job description and education is important to ensure that practitioners, other health professionals and the general public understand the scope of practice and are aware of professional and personal limitations.
The lack of national regulation in the UK has compounded the wide discrepancy in practice and role clarity and raises issues in tracking workforce data as the role develops opportunistically (Maier, 2015). Brook and Rushforth (2011) stated that UK national regulation is essential for public protection because of the high-risk nature of the diagnostic aspect of the role, arguing that members of the public should expect nurses undertaking these advanced roles to work to similar regulated standards as medicine.
From the available literature, it appears that Cornwall is no different to other parts of the UK in terms of educational standards and scope of advanced practice. RCN credentialing (2017) and The Health Education England's advanced practice framework (2017) have both been positive moves towards greater safety and consistency, and will raise awareness for both employers and practitioners of what an advanced role means. While the multi-professional framework (HEE 2017a) is not mandatory and cannot currently be enforced, it is hoped that it will be implemented by 2020. Currently there is positive movement from the Clinical Commissioning Group (CCG) in Cornwall towards ensuring the standards of the framework are met, with clinicians not currently meeting the criteria being offered funding for MSc study or supported to undertake RCN credentialing. Cornwall's Community Eduction Provider Network serves as an education hub for primary care, offering a wide range of advanced level study days and updates covering key subjects, which support and enhance the growth of new advanced clinical roles across the county. Until now, there has been a slow movement towards the uptake of credentialing from clinicians currently in post, and additionally there is poor understanding of standards from employers who are often in desperate need of clinicians to fill roles. CCG support of the framework will raise standards within the county and potentially strengthen the debate for formal registration of advanced practice roles nationally. For clinicians to successfully obtain credentialing, they need to be able to demonstrate that their practice is underpinned by all four pillars of clinical practice and for those who undertake an MSc in advanced practice, the four pillars are now built into the curriculum in order to meet with the standards set by HEE (2017a).
KEY POINTS:
- Advanced roles within primary care are rapidly expanding as GP numbers decline and service demand increases
- There is significant variation in advanced role titles and scope of practice
- Advanced roles in primary care extend not only to nurses but also to other allied health professionals
- Despite an agreed educational standard for advanced practice, it is evident that this is not being met in many instances
- Regulation of the advanced practice title remains hotly debated