Advanced
Practitioner

Advanced Practitioner
AP

How new is this role? [1,4]

The Advanced Practitioner (AP) role has existed for a long time (for nurses at least) but uptake in mental health (MH) has been very low until recently. In 2018 there were 1200 ANPs (Advanced Nurse Practitioners) on the Royal College of Nursing (RCN) credentialing list, but none of these in MH. Accreditation is not compulsory, but it is recommended. There are a variety of places that offer credentialing and NHS England offers the digital badge of recognition of level of practice for APs.
Initially APs were all nurses and called ANPs; this was changed to ACPs (Advanced Clinical Practitioners) when other professions became eligible for the role. NHS England now uses the term AP, partly to simplify the terminology and partly to fit with the levels of practice model.

Rationale [2,3]

According to Health Education England (HEE) (2017):

“A key driver for the implementation of advanced clinical practice is to enable practitioners to practise to their full potential and to optimise their contribution to meeting population and individuals’, families’ and carers’ needs through different models of service delivery and multidisciplinary working.”

Training [1,3]

Initially there was no specific training for the role, although non-medical prescribing was expected to be part of the ANP qualification.
There is now a Master’s in Advanced Clinical Practice that is widely available and it is increasingly expected that APs have this qualification.
Specific MH ACP training became available in 2015 in England.
Some apprenticeship positions are also available.

Expected pay band [3]

HEE and RCN recommend that an AP with a Master’s in ACP should be paid according to Agenda for Change (AfC) band 8a, however this is not standardised and band 7 is more common.

Is it registered/regulated and by whom? [3]

APs must be part of a regulated profession (nursing, Allied Health Profession [AHP], pharmacy, paramedical etc.) and registered with the appropriate regulatory body.
However, advanced practice is not regulated by any professional body in the UK.
There are numerous accreditation schemes (RCN, NHS England, Royal College of Emergency Medicine) in an attempt to standardise what advanced practice is and how the role is used.
The Nursing and Midwifery Council (NMC) has undertaken a review and recently voted in favour of regulation of APs with a nursing registration. This will only apply to APs who are nurses, however the NMC are working with other health professional regulators to agree standards.

What our research found*

Numbers reported in practice

Every Trust reported having or training at least one AP.
Numbers of APs were highly variable, from 1 to 73 per Trust.
19 Trusts provided specific AP numbers: 14 of these reported having between 1 and 20 APs in post, with most having 10 or fewer.

Insights from qualitative interviews and stakeholder reflection groups (i.e. what is reported to be happening in practice)

Most APs appear to be from a nursing background. Reasons appear to be historical and because some Trusts insist on non-medical prescriber status. APs are therefore newer in health professions other than nursing, for example, in occupational therapy, social work or physiotherapy.
APs are said to have improved multi-disciplinary team (MDT) working: “...they're kind of leading in a lot of the MDT space and really, really, very useful. Well respected, leading care in a lot of places” [Interview Participant G1].
They are present in a wide variety of clinical settings: inpatient, community, rehabilitation, specialist services, primary care, dual diagnosis services, intensive care, forensic, older people’s and ADHD services, high security hospitals and in child and adolescent MH services.

Reported drivers for/advantages of implementing the role included:

- - filling gaps in doctor rotas
  - helping develop services
  - offering a clinical career pathway (which may also improve retention)
  - bridging a gap between primary and secondary care
  - providing education and support to others in teams
  - helping with Quality Improvement (QI) projects
  - leading across rather than within professions
  - focusing on physical health in the MH setting.

Challenges to implementation included:

- - lack of understanding of the role among APs themselves and their colleagues
  - lack of investment and long-term funding for the role post-training
  - difficulties securing placements to obtain the required learning
  - ability to prescribe confined to certain professions only
  - lack of standardised national governance
  - lack of MH specialisation in the Master’s in AP
  - resistance to the role from other staff (mainly doctors and senior nurses)
  - structural barriers e.g.,Trusts structured in silos with separate HR function
  - managers prevented from paying at higher bandings
  - difficulties getting supervision in place
  - lack of strategic development and succession planning.

* Research findings are based on 1) interviews with heads of HR or workforce leads in English MH Trusts and 2) stakeholder reflection groups with experts on new roles in MH services. The ways in which new roles were reported to be working in practice could differ within and/or between MH Trusts.

Sources [1-4]

Allabyrne C et al. (2020) Advanced nursing practice in mental health: towards parity of esteem. Nursing Times [online]; 116: 12, 21-23. Advanced nursing practice in mental health: towards parity of esteem
Lawler J et al. (2020) Workforce experience of the implementation of an advanced clinical practice framework in England: a mixed methods evaluation. Human Resources for Health 18:96. Workforce experience of the implementation of an advanced practice clinical practice framework in England
Health Education England, NHS Improvement and NHS (2017) Multi-professional framework for advanced clinical practice in England. Multi-professional framework for advanced clinical practice in England
Manley K (1997) A conceptual framework for advanced practice: an action research project operationalizing an advanced practitioner/consultant nurse role. Journal of Clinical Nursing 6 179-190. A conceptual framework for advanced practice