The role of an Advanced Clinical Practitioner could be characterised as a role searching for a purpose. This post suggests a purpose, to meet the rehabilitation needs of people with Long Covid. They could, eventually, help increase and improve all rehabilitation services. This post reviews how the role emerged over the last 30 years or more, very slowly. It discusses why the idea of an Advanced Clinical Practitioner role or status, available to any non-medical healthcare profession, has been developed. It then suggests that the situation is similar to that for doctors; the doctor acquires expertise in medicine, and then learns about rehabilitation and how to use medical knowledge within rehabilitation. At present, no other profession can acquire two areas of expertise. The Advanced Clinical Practitioner role could enable any healthcare professional to acquire expertise in rehabilitation, so that any healthcare professional can then use their professional expertise much more widely and effectively.
I was recently approached for advice by someone developing educational standards for Advanced Clinical Practitioners in rehabilitation. It is intended that the role can be filled by someone coming from any profession. Naturally I was interested. It made me search to see what was known, the history behind this development etc. I wondered whether the role and idea could be developed to improve rehabilitation services. But first I needed to know what Advanced Clinical Practitioners are!
Health Education England set out the characteristics of Advanced Clinical Practitioners here; they are shown below. The multi-professional framework which informs the current developments was drawn up by a working party, published in 2017, and it is is available here. The working party did not have any rehabilitation specialists as far as I can judge. A report discussing aspects of education for Advanced Clinical Practitioners was published in 2018. (here) Again I do not think anyone with rehabilitation expertise was involved. Last, the protocol for a scoping review looking for evidence about the effectiveness (or otherwise) of advanced clinical practitioners, published in 2020, is available here.
Advanced Care Practitioners seem to be ‘work in progress’, still not fully worked out. Where did they come from?
Context – history
I have increasingly realised, as I get older, that history is vital not only clinically, when exploring the nature of a patient’s concerns, but also when considering any idea, service development, management problem, suggested re-organisation of health services (!) etc. What follows arises from my brief exploration of the Advanced Clinical Practitioner, undertaken using Google.
It is difficult to discover when the term, Advanced Clinical Practitioner, evolved. From 1980 or before, there have been articles and documents referring to nurses or other non-medical healthcare professionals being able to gather advanced expertise. For example, in 1982 P Benner published “From novice to expert”, setting out seven stages; (here) it concerned nursing and it is still referred to. (here)
The terms used vary. Most use the word, advanced, and imply that this refers to greater expertise:
- a higher level of professional knowledge and skills; and/or
- taking more responsibility for clinical decisions; and/or
- developing new areas of clinical knowledge and skills outside core professional areas (e.g. using and prescribing drugs); and/or
- taking a broader view of the patient’s situation, sometimes termed being holistic.
The reasons given for developing advanced level practitioners, sometimes specifying the profession, sometime simply refering to a clinician, and sometimes specifying an area of practice such as oncology, also vary. They include:
- filling gaps in the workforce, usually medical;
- developing and recognising the increasing clinical expertise of the individual;
- reducing the loss of skilled and experienced professionals, who want to progress but have reached the highest available paid professional level; and
- improving patient care through more flexible working of individual team members.
I have not found any good explanation of any of the terms used before the definition given by Health Education England in 2017 (here):
“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 and area 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.“
This brief, non-systematic review suggests that, so far, advanced clinical practitioners are intended to provide people working in professional roles within healthcare the opportunity to develop roles that require high levels of professional knowledge and skill, often in some specific clinical area, while additionally taking on more general clinical roles related to their expertise. These may include taking on roles normally taken on by other professions, predominantly but not only by doctors.
For example, an advanced clinical practitioner who initially trained as a nurse might take responsibility for monitoring and even altering the dose of specialised oncology treatments, a role once undertaken by doctors. The nurse might also coordinate other aspects of oncological management such as providing psychological support, arranging a wig to cover hair loss, and advising on employment support available. They would be paid more.
At present, however, there is little consistency across roles and little consistency in terms used. It seems as if the title is used to create individual posts to fill some specific need, offering more pay and responsibility but still largely based on a single profession. There is also little evidence about effectiveness, but this is not surprising nor is it concerning because one should not expect to find evidence about a single profession working within a team. (see here)
The idea of advanced clinical practitioner is best considered as an idea that is still looking for further specification. In rehabilitation, the idea is the solution to a problem: how does one show and validate specific expertise in rehabilitation? An unsolved problem has met a solution that, so far, has not found its purpose.
Rehabilitation Advanced Care Practitioner role
The section of this website on Rehabilitation Capabilities (here) set out seven capabilities that would characterise a professional as having significant areas of knowledge and skills, in addition to their professional knowledge and skills, such that they were an expert in rehabilitation. The section identified that, at present, there is no body or organisation that can validate acquisition of the expertise.
Historically the concept of advanced clinical practitioners evolved in response to two needs; allowing professionals who already have high levels of specific professional expertise to broaden the scope of their clinical work, without having to move into management to progress their career; and enabling them to take on higher-level, and more complex, patient management roles.
Acquiring rehabilitation capabilities would fit perfectly into the advanced clinical practitioner role: it would be clinical, it depends upon specific expertise, and it is based on, and it is broader than, any specific professional expertise.
Medical training in rehabilitation illustrates this model. The doctor starts with considerable medical expertise in an area of medical practice, and then he or she spends four years principally learning about rehabilitation and how to apply medical skills within rehabilitation. As in most specialist medical training programmes, the trainee learns a bit more about specific medical matters, but the majority of the training is about broadening expertise.
The training programme teaches the trainee to:
- see how medical treatment fits into an overall management programme;
- judge when it is better not to treat;
- consider when other treatments might be more appropriate, given the context;
- discuss treatments with patients, families and other team members;
- improve services etc.
These are just the skills an advanced clinical practitioner needs.
Locating professionals with additional expertise in rehabilitation within the framework of Advanced Clinical Practitioners seems to fit well with the role defined by Health Education England. Some further work is needed, but not too much given the long-standing model of medical training, which enables doctors to acquire a similar status and set of skills.
The actual capabilities need to be considered. The capabilities needed by doctors are now fixed – the General Medical Council are reluctant to allow change without strong reasons. It is my opinion that the slightly modified capabilities I have proposed on this website are appropriate. They are derived from the medical capabilities, which were open to review by anyone, not just doctors. No-one suggested any changes. Nonetheless, a review by a wider body of professions would be wise, but the focus on high-level outcomes is essential and should be retained.
The knowledge and skills associated with each capability outlined on this website also need review. They probably need some expansion and clarification.
Any training or educational programme will need to recognise that each professional needs to maintain and improve their own professional expertise through continuing professional development. This requirement has been incorporated into one of the capabilities.
Last, it might even be necessary to develop a syllabus. Many people seem very dependent upon having a syllabus. If one is developed, it needs to focus on rehabilitation, and must be separate from and independent of the professional expertise of any one profession. There is a medical syllabus. (here)
To conclude, rehabilitation has a marvellous opportunity to grow as a speciality and area of expertise open to all professions. This is particularly needed at present, with an anticipated large increase in need for rehabilitation associated with Long Covid. Developing Advanced Clinical Practitioners in Rehabilitation will greatly increase patient access to rehabilitation expertise, more quickly that any increase in doctors can possibly occur.