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Evaluation of the Advanced Practitioner Roles
Miller L, Cox A, Williams J
a study commissioned by Skills for Health, in partnership with NHS West Midlands
In February 2008 Skills for Health, in partnership with NHS West Midlands, commissioned the Institute for Employment Studies to undertake a national evaluation of five Advanced Practitioner roles introduced under the New Practitioner Programme. The research involved a review to identify appropriate measures to use in the evaluation; a survey of sites at which Advanced Practitioners were employed and, for comparison, a similar survey of sites without these roles; and case studies of implementation sites. Although great care had been taken in designing the survey documents, there was a low response rate, therefore the data from the survey should be treated with caution. The report is based on a combination of evidence gained through the survey and richer qualitative data gathered during the four case study visits.
The organisational impact
Impact on work practices
In the majority of trusts Advanced Practitioners were running separate or parallel sessions to consultants and in some they manage their own caseload. Where Advanced Practitioners were responsible for separate sessions these were either additional sessions to those run by medical staff or in some cases replaced medical personnel, enabling medical practitioners to undertake other activities or concentrate on more complex cases. In some sites however Advanced Practitioners were restricted in the tasks they could undertake through lack of support from consultants.
The impact on work practices was widely believed to have brought improved service delivery. The benefits cited included reduced length of stay, improved patient care, reduced costs, a more efficient service and improved patient and staff satisfaction. However, because of the relative newness of the roles trusts had few data to support these claims.
Junior doctors’ hours
The single most common reason cited for introducing the Advanced Practitioner posts was to support the reduction in junior doctors’ hours, and the survey responses and the case study interviews showed that the roles were having the desired effect. Two trusts provided data indicating that junior doctors’ hours had reduced since the Advanced Practitioner posts had been introduced; however, without the comparison data from non-Advanced Practitioner sites it is not possible to draw conclusions from this, as it is likely that all trusts are seeking ways to reduce Junior Doctors’ hours.
Opting in to the Advanced Practitioner Programme
The majority of the Advanced Practitioner sites had introduced the posts as a way of helping them meet the target of reducing junior doctors’ hours. The other main reason cited for introducing the posts was to encourage inter-professional working. Survey respondents also mentioned specific service needs and service redesign to meet access and financial targets.
Decision-making and leadership
The survey indicated that a senior individual – typically a clinical or nursing director or a consultant – had led the process in most places. The case studies confirmed that it was typically one inspired and committed individual who had spearheaded the development process, and where these individuals had left the project had often lost momentum.
At no site had an HR representative been involved in leading the process and where they were involved, it was typically in a specific advisory capacity. There was also little evidence of HR involvement in embedding the posts or in workforce planning to incorporate the posts.
Consultation on and development of the AP role
At eight of the Advanced Practitioner sites there had been an internal consultation process. The people most often consulted were medical colleagues, senior managers and executive directors, senior nurses and other senior medical staff. Around half had consulted education and training providers.
Similar individuals were involved in the development programme. In only one case was there any HR involvement and that was restricted to advising on employment-related issues (eg contracts and terms and conditions).
Business and commissioning plans
Only three of the twelve sites that responded had incorporated development and introduction of the Advanced Practitioner roles into their business plan. Just four had incorporated education and training for these roles into their commissioning plans, which has implications for sustainability.
The majority of sites had not followed Department for Health (DH) Good Practice Guidance on communicating the new roles within trusts. A minority of the sites had a communications strategy for the Advanced Practitioner posts although most reported having used a range of communication methods to promote the new roles. In two-thirds of sites team meetings had been used to explain the roles. Only five of the twelve trusts reported having appointed a local champion to promote and coordinate introduction of the role.
Identifying success criteria
Only four sites had identified criteria against which the success of the programme could be judged. Only two sites had planned any assessment and in one of these there was now little interest in auditing the project. In two of the case study sites Advanced Practitioners were becoming involved in auditing the impact of their work.
Recruiting and developing Advanced Practitioners
Nine of the sites had limited their recruitment to internal applicants, either through open internal advertising or targeted internal advertising, while three had advertised the posts externally.
A majority of trusts had specified minimum prior qualification levels for potential Advanced Practitioners, with most indicating they required degree-level – or equivalent – individuals. One scheme had tested the recruitment of science graduates (that is, personnel with no previous experience of providing direct healthcare). Although this had been an option for all of the development sites only one of the case study sites had tested this recruitment model, where it was found to have been very successful.
Training for the posts
At the majority of sites the Advanced Practitioners had completed their training and no others were currently being trained. Only two sites reported trainees leaving before the end of the training period, and two sites had trainees still in training. Training was supplemented in most of the sites by mentoring provided in the main by senior clinicians or consultants.
Accessibility of the training
Most Advanced Practitioners were trained through programmes developed as part of the pilot. In some cases this was inconvenient, with individuals having to undertake week-long block training far from their home and employment.
In one case, the training programme was delivered electronically, with supporting tutorials from clinicians. This had been very well received by the trainees, who had recommended the training modules to other staff members, such as SHOs.
The majority of Advanced Practitioners remained in post at the sites that had provided their training. Some however had moved on since completing training, often to advance their careers. In some cases individuals had moved into Advanced Practitioner posts on higher pay grades at other organisations (one training site had lost both its Advanced Practitioners almost immediately following completion of their training), or had moved into more senior/managerial positions in the NHS. Others had taken up places at medical school.
All the Advanced Practitioners were enthusiastic and positive about the roles. However, they noted that options for further career progression appear limited. Many were focusing on developing within the role to create a niche position for themselves. As the roles are relatively new there is no clear career pathway at present other than moving into management positions or, potentially, other types of work such as academic or research posts, although no interviewees identified these as potential routes.
In addition, there are few opportunities for Advanced Practitioners to engage in Continuing Professional Development (CPD). Advanced Practitioners are not state registered posts and this means that there are currently no professional requirements regarding minimum levels of CPD as there are, for example, for nurses. In addition, the failure to incorporate the posts into the business and commissioning plans of trusts means that in many cases money had not been allocated for continuing professional development for this staff group.
Sustainability of the training
The training for Advanced Practitioners had been costly during the pilot phase as it was specifically developed for relatively small numbers of trainees. There had been no attempt to identify areas of commonality, either between training for different groups of Advanced Practitioners or between training for Advanced Practitioners and for other staff groups. The case study interviews identified a number of areas of overlap that could be the basis for more economical delivery of future training for Advanced Practitioners. In addition, a distance learning programme delivered electronically had been extremely well received, and again constitutes a possible way of delivering training more cost-effectively in future.
Sustainability of the posts
Most sites were not intending to commission further Advanced Practitioner posts, but at the two sites where more roles were planned, these were the same type of role already used. At one case study site a consultant wanted to begin training more Advanced Practitioners but was having difficulty gaining agreement at trust level.
Clarity of the role
There continues to be a widespread lack of clarity about, and understanding of, the Advanced Practitioner roles. As a result, some colleagues feared the role would encroach on their areas of professional responsibility. The majority of trusts had had no real communication plan and only a minority had champions to promote the new roles. Individuals – Advanced Practitioners and consultants – were attempting to explain the new roles to colleagues and reassure them that there would be no displacement of existing staff.
The attitudes of colleagues
On the whole colleagues’ attitudes were positive. Where there was a lack of clarity about the role, hostility sometimes arose from fear of professional encroachment. Some junior doctors and consultants have refused to work with Advanced Practitioners but most have quickly been won round when they see the advantages both in terms of support for their own work and in terms of improved service for the patients.
Fitting new roles into existing organisational structures
Projects had often focused on development of the new roles, often without considering how the Advanced Practitioners would fit into existing teams and organisational structures. In some cases the organisations only started to consider how they were going to use the new staff after the Advanced Practitioners had completed their training. Some sites were unsure if there was a job description for the posts. At one of the case study sites the tasks allocated to Advanced Practitioners changed from year to year according to the training needs of junior doctors.
Despite the positive response that Advanced Practitioners had received in the majority of sites, and the perceived benefits they brought, survey responses indicated that just three of the sites were considering commissioning more Advanced Practitioner posts. Six of the responding sites were not planning to commission any more and three did not know if they would commission any further posts.
The wider picture
Because the survey had failed to provide the quantitative evidence required to demonstrate the impact of introduction of the Advanced Practitioner role, Skills for Health asked IES to undertake a further search through the literature, in particular focusing on those countries in which Advanced Practitioners had been in post for longer than in the UK.
The follow-up literature review revealed that, outside the UK, there is only restricted quantitative data available at present, even in countries where Advanced Practitioners were introduced some years earlier than in the UK.
A major factor influencing the extent to which cost savings are made is the model of service delivery in operating in the organisation within which the Advanced Practitioner works.
Furthermore, many existing data sets used in auditing health service performance currently do not reflect the role of Advanced Practitioners, which restricts the data available for analysis.
Summary of findings
Significant investment in the training and development of Advanced Practitioners has taken place with centralised funding based on a bidding methodology that required bidders to provide assurances that, where positive outcomes are demonstrated, measures would be taken to embed the roles in the organisation and promote the roles to other organisations.
In almost all cases Advanced Practitioners have received a warm reception from their colleagues and provided positive benefits to patient care. In the majority of cases respondents and interviewees reported a range of ways in which the Advanced Practitioners had helped the team improve service outcomes and team productivity and increased team capacity.
Top-level commitment (at Executive level) was mostly seen only during the initial bid for development money. In most cases, professional advice from HR and finance departments was absent from both the initial phases of the role development and the continued promotion of the role as part of the organisational development process. There is little evidence that trusts have actively planned for the future incorporation of these roles within either their business/workforce planning or their education and training commissioning processes. Development work for the Advanced Practitioner roles had often been conducted with no real plan for how the roles would be incorporated within the team. In some cases the roles did not have job descriptions that reflected the new and enhanced competences acquired and how these had been put into practice.
The deployment of new or enhanced roles within an organisation will almost inevitably require some change to organisational structures and procedures. Focus on, and funding for, development of these roles led in many cases to organisations taking insufficient steps to consider the requirements for organisational development and change that would be needed to incorporate these roles successfully within team and organisational structures and future plans.
The Department of Health Good Practice Guidance emphasises the need for effective communications in successfully bringing about organisational changes of this nature. In the majority of cases, communication was left to the clinical champions who led the role development work or the individual practitioners themselves.
Local clinical champions and managerial advocates seeking to provide a clear argument in support of these posts have had difficulty obtaining clear data that demonstrate the cost-effectiveness and service benefits of these posts. Trusts have taken few steps to assess the impact of introducing the posts, as they would be routinely required to do, for example, if they asked for funding for additional consultants.
With only a few exceptions the costs for delivery of the training programmes are high because most of the roles are dependent upon extending the skills and competences of experienced practitioners through secondments. There appears to have been little attention to date to how costs could be reduced in the longer term, such as through defining common competences. This is surprising given the overlaps between the training of several of the Advanced Practitioner roles and between the Advanced Practitioner training programmes and other types of post-registration training for NHS professionals. Economies of scale will need to be considered if these training programmes are to continue to run.
Given the above, we make the following recommendations:
Direct or stepped entry into some programmes and the use of alternative funding streams to cover education costs should be maximised. Discussions should take place with funding bodies such as the Higher Education Funding Councils about the range of programmes that could be funded as part of the NHS Career Pathway to ensure the best value is gained from all the investment streams across healthcare programmes.
Given the current shortage of data, trusts might consider using the Skills for Health questionnaire as a basis for designing future procedures to capture the relevant information needed to assess cost-effectiveness.
The Advanced Practitioner roles have had distinctive benefits which, for various reasons, trusts have found difficult to document. The need to improve the evidence base on Advanced Practitioner role impact gives rise to two main challenges: securing resources to implement the roles to ensure that they are sustainable, and how best to diffuse innovation across the NHS.
Like many ‘good ideas’, Advanced Practitioner roles were not being systematically spread across NHS trusts or regions, so policy-makers may wish to consider actions they can take to enable more effective intra- and inter-organisational learning. There may be a role for Skills for Health to play, together with the National Health Service Institute for Innovation and Improvement and the Department of Health, in fostering action learning projects to promote Advanced Practitioner roles and disseminate and embed other innovations.
Evaluation of the Advanced Practitioner Roles, Miller L, Cox A, Williams J. Report 465, Institute for Employment Studies, 2009.
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