In 2017, Health Education England (HEE) (now NHS England Workforce, Training and Education) published the ‘Multi-professional framework for advanced clinical practice in England’. For the first time, this framework set out an agreed definition for advanced practice for all health and care professions and articulated the capabilities which underpin advanced practice across the four pillars of clinical practice, leadership and management, education and research. Since then, the Centre for Advancing Practice (‘Centre’) and the Regional Faculties for Advancing Practice (‘Faculties’) have been established to drive system-level leadership for advanced practice. The Centre and the Faculties work together to grow and support the development of a multi-professional advanced practice workforce. They promote system-wide understanding of how this workforce can transform services to meet the needs of people, their families, and carers, while also helping to build clear, sustainable career pathways that support workforce development, retention and transformation.
The 2017 framework has largely stood the test of time, which is a tribute to the collaborative expertise of all those colleagues who helped HEE to develop it. This new edition is a refresh, rather than a wholescale revision. The existing capabilities have been retained, without significant amendment, heeding the advice from stakeholders to avoid unhelpful disruption to healthcare and higher education. These sectors make embedded use of the capabilities of the framework for training advanced practitioners in partnership with each other. Accordingly, the Centre's approach in reviewing the framework has been focused on refreshing the introductory and supporting material, to contextually contemporise it, improve clarity and bolster inclusivity. The key processes the Centre has engaged in have been an exercise to map the existing framework capabilities against the correspondent advanced practice frameworks in other countries in the UK, and a scrutiny of the existing framework content with an equality, diversity and inclusion lens.
From the perspective of inclusivity, this second edition of the framework uses the language ‘advanced practice’ and ‘advanced practitioner’ rather than ‘advanced clinical practice’ and ‘advanced clinical practitioner’. The move to these more inclusive terminologies reflects both the diverse range of role titles held by healthcare professionals working as advanced practitioners, and the wide range of settings across health and care where advanced practitioners work, for which, in many circumstances, the application of the term ‘clinical’ is neither appropriate nor relevant. In this inclusive context, the term ‘advanced practitioner’ is seen as an umbrella term representing the diverse range of the multi-professional role titles used by registrant healthcare professionals working in advanced practice roles, whether that be in roles contiguous to medicine, specialist roles, generalist roles or unique roles.
The 2017 publication of HEE's framework stimulated an expansion in the awareness and uptake of advanced practice across many care settings, particularly so with a multi-professional emphasis on ‘Advanced Clinical Practitioner’ (ACP) roles. Subsequently, some observers of advanced practice and the advanced practice community itself felt that the evident multi-professional emphasis of the original version of the framework (HEE, 2017) denuded the professional identity of individual practitioners and privileged ‘generic’ advanced practice roles. The Centre also received feedback that the previous use of ‘clinical’ in the first edition of the framework has inadvertently led to conclusions that advanced practice is a generic role, rather than a level of practice deployed in a variety of multi-professional roles and contexts. However, such generic conceptualisation of advanced practice roles was not the intention of HEE's (2017) multi-professional framework, since a clinician's discrete professional identity as a healthcare registrant is of fundamental importance for enabling their subsequent multi-professional practice as an advanced practitioner (Barratt, 2022). Accordingly, it is also acknowledged that an ACP is only one example of the wide range of ACP roles healthcare professionals may be employed in, hence the move in the refreshed framework to use the more inclusively representative term of ‘advanced practitioner’.
The framework further enables a more consistent understanding of advanced practice, by articulating the capabilities that underpin practice at this level, within the contemporary policy context of advanced practice development and innovations. Also included is overview guidance on implementation of advanced practice for service providers and employers, such as workforce transformation funding arrangements for advanced practice training, supervision for advanced practitioner trainees and governance of advanced practice in provider organisations. This framework also supports the career development, retention and practice of advanced practitioners working directly with people, their families, and carers who have the direct responsibility for assessment and management of complete episodes of care involving complex decision making.
The capabilities articulated in this framework apply to all advanced practitioners, regardless of the setting, practice area and job role. As such, the capabilities across the four pillars are applied in different individual ways depending on the profession, role, population group, setting and sector in which an advanced practitioner is working. Advanced practitioners have a crucial role to play in eliminating discrimination and promoting equality and diversity. It is the collective responsibility of the advancing practice community to rise to the challenge and ensure that all health and care provision needs of the diverse population are met, regardless of their background. The NHS has responsibilities to eliminate any discrimination; the NHS equality, diversity and inclusion (EDI) improvement plan (NHS England, 2023), shows its commitment to eliminating inequalities, discrimination and marginalisation experienced by staff, people, their families and carers and the wider community.
The capabilities outlined in this framework emphasise the importance of person-centred care, which meets the needs of individuals. Woven throughout is the principle of inclusivity; to demonstrate the importance of this principle, a rephrasing of capability 2.1 of the leadership and management pillar now reflects this inclusive emphasis. This framework fulfils the requirements of the NHS in England, but does not necessarily directly apply to the other countries of the UK. However, the currently available equivalent frameworks in Wales, Scotland and Northern Ireland were reviewed and mapped to the framework's capabilities to ensure there were no significant gaps (Department of Health, Social Services and Public Safety, 2016; Scottish Government, 2017; 2021a; 2021b; Department of Health, 2019; Health Education and Improvement Wales, 2023). The Centre continues to work with colleagues involved in the development of the advanced practice workforce in the other UK countries to collaborate on matters of mutual interest and support UK-wide advanced practitioner workforce mobility.
The refreshed framework presents a more inclusive definition of advanced practice being delivered by accomplished registered health and care professionals, which is a level of practice characterised by a high degree of autonomy and designated responsibility for complex decision making. This advanced level practice is underpinned by a post-registration master's level award, or equivalent, undertaken by an experienced practitioner, which encompasses all four pillars of advanced practice. Advanced practice further embodies the ability to manage care in partnership with individuals, families, and carers. It includes the analysis and synthesis of complex problems, and management of clinical risk and uncertainty across a range of settings, enabling innovative solutions to expedite access to care, optimise people's experiences and improve outcomes. It is important to recognise that registrant healthcare professionals can be prepared to function effectively as advanced practitioners, either with a post-registration a master's level award or equivalent means, such as mixed modes of combined experiential and formalised learning correspondent with master's level attainment. Furthermore, it is essential for registrants seeking to become advanced practitioners to progress past the newly qualified foundation or preceptorship periods of practice as confidence in being a registrant is an important requirement of being an advanced practitioner.
The theme of inclusivity is also extended to considering which health and care practitioners it is of relevance to. There are nine statutory regulators of health and care professionals in England overseen by the Professional Standards Authority for Health and Social Care (PSA). While some other professions are not regulated by law, they are registered by ‘accredited registers’ also overseen by the PSA. Currently, the advanced practice development activities of the Centre and the regional faculties focus on the statutory regulated professions and the delivery of NHS-funded and other publicly funded services. While detailed regional requirements will vary, NHS England funding for trainees on advanced practice programmes is normally limited to: an individual being registered with the appropriate statutory regulator; having employer support for undertaking training; and having a funded, identified advanced practitioner position at completion of their training. The refreshed framework notes the Centre's commitment to exploring whether other professions on PSA accredited registers that are not currently subject to statutory regulation will require future access to funded advanced practice education, training and development opportunities to support service and workforce transformation.
It is also noteworthy that the extant capabilities refer to advanced practitioners being able to ‘initiate, evaluate and modify a range of interventions, which may include prescribing medicines, therapies, lifestyle advice and care’ (capability 1.7). However, the framework observes that prescribing medicines is not necessarily a contingent feature of all advanced practice roles, particularly so when the diversity of advanced practitioners and settings are considered. It is hoped that the publication of the refreshed framework will enable those involved in advanced practice innovations and the recipients of care from advanced practitioners to more clearly and consistently understand the contemporary nature of multi-professional advanced practice roles across all health and care settings.