Whole systems approach
Advanced clinical practitioner
development and identity in primary care
Juliana Thompson, Anne McNall, Sue Tiplady, Phil Hodgson and
Department of Nursing, Midwifery and Health,
Northumbria University, Newcastle upon Tyne, UK
Purpose –The purpose of this paper is to ascertain primary care advanced clinical practitioners’(ACP)
perceptions and experiences of what factors influence the development and identity of ACP roles, and how
development of ACP roles that align with Health Education England’s capability framework for advanced
clinical practice can be facilitated in primary care.
Design/methodology/approach –The study was located in the North of England. A qualitative approach
was used in which 22 staff working in primary care who perceived themselves to be working as ACPs were
interviewed. Data analysis was guided by Braun and Clarke’s (2006) six phase method.
Findings –Five themes emerged from the data –the need for: a standardised role definition and inclusive
localised registration; access to/availability of quality accredited educational programmes relevant to primary
care and professional development opportunities at the appropriate level; access to/availability of support and
supervision for ACPs and trainee ACPs; a supportive organisational infrastructure and culture; and a clear
Originality/value –Findings have led to the generation of the Whole System Workforce Framework of
INfluencing FACTors (IN FACT), which lays out the issues that need to be addressed if ACP capability is to
be maximised in primary care. This paper offers suggestions about how IN FACT can be addressed.
Keywords Primary care, Workforce, Workforce planning, Nursing, Advanced clinical practice,
Allied health professional
Paper type Research paper
The challenges that primary care is facing have been well documented. Issues include
increasing demand on primary care services to support an ageing population with
growing numbers of older people living with complex multi-morbidities and frailty
(Barnett et al., 2012; NHS England, 2014, 2019). In addition, the primary care sector is faced
with increasing budgetary and organisational pressures (Fawdon and Adams, 2013),
rising demand and increased patient expectations (Williams, 2017), and continuing
problems with staff shortages, particularly general practitioner (GP) shortages (NHS
England, 2019). The Centre for Workforce Intelligence (CFWI, 2014) identified that the
existing GP workforce did not have sufficient capacity to meet current and expected
patient needs. The “Five Year Forward View”(NHS England, 2014) suggested radical
changes to current care models, which would support out of hospital care and the
integration of health and social care. In response, the “General Practice Forward View”
(NHS England, 2016) aimed to support general practice with a strategy that included
creating 5,000 additional doctors and at least 5,000 non-medical staff working in general
practice by 2020/2021, and investing in development programmes for practice nurses and
Journal of Health Organization and
Vol. 33 No. 4, 2019
© Emerald Publishing Limited
Received 18 November 2018
Revised 29 January 2019
18 April 2019
Accepted 5 May 2019
The current issue and full text archive of this journal is available on Emerald Insight at:
This paper reports on an aspect of a wider study commissioned and funded by Health Education
England to scope the profile and application of ACP in primary care in the North of England, and
identify any specific developments required to support ACP is to be effectively maximised “at scale”
within primary care. The authors acknowledge the involvement in the study of Jane Smiddy, Carol
Wills, Karen Elton, Lynn Craig, Sue Tweddell and Jonathan Yaseen.
administration staff. The focus on primary care continues in the recently published NHS
Long Term Plan (NHS England, 2019). This report proposes extending the skills of
registered professionals and developing advanced clinical practitioner (ACP) roles.
These changes aim to mitigate some of the challenges of an overloaded GP workforce,
offering opportunities for improved patient-centred care, organisational efficiencies and
rewarding careers for health professionals.
Currently, ACP roles are utilised in a number of ways within primary care. NHS Digital
(2018a) data for general and personal medical services suggest GP practices employ ACPs
with nursing, pharmacy, physiotherapy and paramedic backgrounds. These staff primarily
provide care for presenting patients from initial clinical assessment to diagnosis, treatment
and evaluation of care (Swan et al., 2015). Clinical Commissioning Groups (CCGs) and NHS
Trusts employ ACPs as nurse consultants, extended practice physiotherapists and
advanced practitioner speech and language therapists. Occupational therapists, dieticians
and opticians working as advanced practitioners are increasingly being employed (NHS
Digital, 2018b). These CCG/NHS Trust employees are expert clinicians, lead the
development of non-medical led services and lead service improvement and service
transformation initiatives (Chartered Society of Physiotherapy, 2016; Pottle, 2018).
A number of studies suggest the development of non-medical advanced practice roles in
primary care is a response to medical staff shortages resulting from difficulties in
recruitment and retention (Delamaire and Lafortune, 2010; Barton et al., 2012a; Williams,
2017). These authors suggest that to a large extent, the introduction of these roles involves
a substitution of tasks away from doctors, with the main aim being to reduce demands on
doctors’time, improve access to care and reduce costs. Participants in Clay and Stern’s
(2015) study “Making time in general practice”commissioned by NHS England, estimated
that 27 per cent of GP appointments were potentially avoidable if the bureaucratic system
operated differently. The most common potentially avoidable GP consultations were
where the patient would have been better served by consulting someone else in the wider
primary care team, for example, an ACP. A number of studies identify the benefits of the
ACP role. For example, systematic reviews into the effectiveness of the ACPs in primary
and community care services undertaken by Begley et al. (2013), Donald et al. (2013) and
Laurant et al. (2018) suggest ACP care improves patients’functional, health and
psychological status; improves rates of patients’goal achievements and increases levels of
family-expressed satisfaction. Swan et al.’s (2015) systematic review of the quality of ACP
care delivery suggests that ACPs in primary care settings perform as well as medical staff
in terms of clinical outcomes and patient satisfaction, but at a lower cost.
Despite the benefits that can arise from ACP care, a number of challenges to the
development and effectiveness of the role have been identified. As highlighted above, the
development of advanced roles in primary care has been reactionary in nature. In addition,
in England, primary care is provided by a variety of health and social care providers
including GP practices (which are independent employers), NHS Trusts, private social
care providers and voluntary services. A number of studies suggest that these two factors
have led to difficulties in defining, further developing and valuing the role. Bryant-
Lukosius et al.’s (2004) evaluation of the implementation of ACPs identifies a range of
problems relating to these difficulties: inconsistency and confusion about job title
terminology; lack of clear definition in relation to role and objectives; and limited use of
evidence-based approaches to guide role development, implementation and evaluation.
A decade later these issues remain pertinent. Surveys and studies exploring ACP job titles
and descriptions have identified considerable variation (East et al., 2015; Elliot et al., 2016).
Barton et al. (2012b) and Fawdon and Adams’s (2013) studies identified that recruitment
to, and development of, advanced roles is ad hoc. These authors argue that such role
inconsistency and confusion leads to inefficiencies in care, inconsistencies in levels of
competency, duplication in care activities, ineffective professional relationships and
undeveloped career structures and pathways.
A number of suggestions have been made about how to address inconsistency in ACP
roles and competence. For example, some organisations have attempted to define the role.
The International College of Nursing (2008) focussing specifically on nurses, rather vaguely
defines the role as:
A registered nurse who has acquired the expert knowledge base, complex decision-making skills
and clinical competencies for expanded practice, the characteristics of which are shaped by the
context and/or country in which s/he is credentialed to practice.
In England, more recent definitions have been extended to include descriptions of expected
practice levels, and minimum education standards. For example, DH policy statements
expect that ACPs will have successfully achieved Master’s level education (DH, 2010).
Pearce and Breen (2018) provide a definition of ACP identifying that:
Advanced practice is a level of practice, rather than a type of speciality of practice […] advanced
clinical practitioners (ACPs) are educated to Master’s level and are assessed as competent in
practice, using expert knowledge and skills. They have the freedom and authority to act, making
By setting out clear frameworks for Master’s level education, and emphasising autonomous
practice, these definitions suggest ACP roles are not substitutes for medical care, but roles
that enhance services.
Other organisations provide further clarity about the nature of “expert knowledge and
skills”. The DH’s (2010) benchmark for advanced level nursing comprises of 28 elements
grouped under four themes –clinical/direct care practice; leadership and collaborative
practice; improving quality and developing practice, and developing self and others. Health
Education England’s (HEE, 2017) definition is similar in many respects to these definitions,
but highlights the multi-professional potential of the role:
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.
These statements and definitions advocate for agreed standards for ACP as a way forward.
In England, the question of registration of the role, however, has been the subject of
long-standing debate. From a nursing perspective, Barton et al. (2012a) identified that UK
regulatory debates have continued over decades, Ward and Barratt (2005) highlighted
continued interest in this area, and the Nursing and Midwifery Council (NMC) has called for
consultation (RCN, 2010). However, ACPs as part of the NMC and Health and Care
Professions Council (HCPC) registers has remained unrealised. Barton et al. (2012a)
suggested that registration is unlikely and potentially unworkable, and propose advanced
practitioners represent no greater public risk than new registrants, therefore, a separate part
of the register would hold little benefit. Nevertheless, concerns about lack of registration
remain. This has resulted in a number of suggestions about how to regulate the role in the
absence of national registration. Barton et al. (2012b) and East et al. (2015) highlighted the
use of governance via local NHS regulation, and the use of integrated health education
boards. In England, the RCN (2018) has developed the notion of “credentialing”, where
practitioners can apply to be recognised as ACPs via an online application, but this is not
universally recognised as a means of regulation.
Achieving a standardised role definition is not the only challenge in the development
and implementation of the ACP role in primary care. Kennedy et al. (2015) note wide
variation in ACP education programmes offered by universities. These authors propose
that such variation exacerbates inconsistencies in ACP competency levels, and
preparedness for the role. Some studies have proposed that the role is only effective
where service design as a whole is supportive. Imison et al. (2016) caution that careful
attention to service design, executive level commitment to incorporating ACP roles within
business/workforce planning, and effective education, training and commissioning
processes are essential. The authors propose that without these, new and extended roles
will simply supplement the existing workforce, rather than leading and managing care;
cost rather than save; threaten the quality of care; and fragment care. Miller et al.’s(2009)
evaluation of ACP roles, and the West Midlands’ACP framework (HEE, 2015) also
emphasise the importance of executive support and a team approach when introducing
new advanced roles, particularly if roles are to be standardised, sustainable and impact
positively on service outcomes.
Previous literature suggests that the inclusion of ACPs in primary care can enhance care
provision and alleviate some of the workload pressures on GPs. However, inconsistency and
confusion about the scope and competency of ACP activity has led to calls for
standardisation of the ACP role definition, and ACP education programmes and
qualification requirements; ACP registration, and executive level commitment to ACP
development processes. As few studies consider ACPs’perceptions and experiences of the
factors that influence the development and utilisation of the role in primary care settings,
the aim of this study was to explore these factors.
This paper reports on an aspect of a wider study commissioned by Health Education
England to scope the profile and application of ACP in primary care in the North of
England, and identify any specific developments required to support ACP is to be
effectively maximised “at scale”within primary care. This paper does not represent the
study’s findings in entirety, but presents the phase 2 aspect: ACPs’perceptions and
experiences of what factors influence the development and identity of ACP roles, and how
development of ACP roles that align with the four pillars of HEE’s ACP capability
framework can be facilitated.
For the study as a whole, a mixed methods approach was used. As phase 2 focussed on
exploring factors that influence the development of ACPs, a qualitative approach was taken
for this aspect of the study.
The study location was the three HEE regions in the North of England (North West, Central
North and North East). During phase 1 of the study, an online survey was opened to staff
working in primary care in these regions who perceived themselves to be working as ACPs.
Due to the potential for variability in definitions and perceptions about what constitutes
advanced clinical practice, purposive and snowball sampling was used. In total, 116 surveys
were returned. All staff who completed the survey were invited to take part in an interview.
Those agreeing to participate were requested to sign a consent form.
A total of 22 individuals agreed to participate in interviews. In total, 91 per cent were
female; mean age was 49.1 years (SD ¼8.4 years); mean years qualified as a healthcare
professional was 27 years (SD ¼9.8 years), and mean years working as an ACP since
qualification was 13.5 years (SD ¼10.9 years). Table I provides details of participants’job
groups, professional backgrounds and employing sectors.
Individual semi-structured interviews were carried out to explore participants’views
and experiences of their ACP role. Topics covered during interviews were: professional
and educational pathway to becoming an ACP, support required to achieve this, role
activities in relation to the four pillars of the ACP framework, and barriers and
enablers for future development. Participants were interviewed at locations chosen by
themselves, and 15 chose to be interviewed at their work location, 3 were interviewed at
the university and 4 were telephone interviews. As all members of the research team were
involved in interviewing, an interview schedule was used to maximise consistency in
Audio recordings were made of the interviews. Audio recorded data were transcribed
verbatim, then open coded by individual members of the research team. This allowed
elucidation and description of participants’experiences, while creating meaningful themes.
Thematic analysis was chosen as it is “a method for organising, analysing and reporting
patterns (themes) within data. It minimally organises and describes data set in (rich) detail”
(Braun and Clarke, 2006, p. 79). The approach taken was inductive, in other words the
analysis was data-driven, rather than theory-driven. The six phase guide to conducting
thematic analysis, as outlined by Braun and Clarke (2006), was used. During this process, all
transcripts were independently coded by another team member, and the outcomes were
compared with the original coding to validate themes.
Research ethics approval to undertake the study was secured from the Faculty of Health
and Life Sciences, Northumbria University on 16 April 2018.
Findings from the study suggested that five factors had a significant influence. These were:
role definition; access to/availability of quality educational and professional development
opportunities; support and supervision, organisational culture and infrastructure; career
pathway. These factors are discussed below.
(n¼22) Job group
background Employing sector
1 Care home manager Nurse Private
1 Home care provider Nurse Private
1 Care home provider regional manager Nurse Private
1 ACP GP services Nurse Self-employed
1 ACP primary care/lecturer Nurse NHS
2 Clinical commissioning group (CCG) nurse leads Nurse NHS
1 Admiral nurse (dementia nurse) Nurse Voluntary
7 ANP GP Nurse GP practices (3 from GP
2 CCG strategic workforce leads AHP NHS
1 CCG strategic workforce leads Nurse NHS
1 Clinical lead for intermediate care OT Private
1 Practice educator OT NHS
1 Extended scope practitioner/lecturer Physio NHS
1 Specialist dietician for older people Dietician NHS
Participants’responses suggested that there is a lack of standardisation and consistency
with regard to the ACP role. They proposed that an ACP role definition is required that is
standardised across all sectors and organisations working in primary care, and that this
standard definition should be based upon a number of factors. For example, practitioners
need to be able to demonstrate a set of standardised advanced capabilities, if they are to be
assigned the ACP title:
C2: There is such variation of skills in ACP, many working at different levels. If we’re trying to
make it a consistent standard that people meet and adhere to, then there’s a consistency in practice
Some participants said that implementing this requirement would be difficult because ACPs
are employed in different sectors, professions and organisations. A number of participants
proposed that a solution to this problem would be regulation via registration of the role with
the NMC and HCPC:
W1: I would want it to be the NMC that would do that […] our regulatory body. It’s protection for
people who are employing these people. People who are misusing the title.
Participants also suggested that a standardised capability framework and regulation would
inform a standardised practice remit, job titles and job descriptions for ACPs. They
identified that currently there is a distinct lack of standardisation in these areas, resulting in
problems such as varying remits, and confusion about remits and capabilities. Some
participants argued that this leads to inefficiencies in care because the ACP role is not
utilised to its full potential:
W2: I don’t think people really understand it […] that the term clinical specialist or nurse
practitioner or practice nurse or non-medical prescriber, and advanced practitioner […] And the
impact is that I work in one place and I do all my referrals to consultants and two-week waits and
things. And, in another place that I work, they don’t think that that’s really my role to do that, so it’s
Findings indicated that practice remits, and job titles and descriptions are often driven by the
needs of individual employing organisations, rather than the ACP capability framework.
Many interview participants, particularly those employed in GP practices, proposed that they
are primarily employed to ease the pressure on GPs affected by GP recruitment problems,
which leads to the perception that they are “inferior GPs”(C3). Some participants said because
they are employed to “fill clinical gaps”they are not required, or given opportunities to
practice advanced level skills in leadership, education or research:
W2: It’s frustrating. Certainly, all I do is clinical practice. Because I don’t do any leadership. I don’t
do much teaching. And I don’t do any research. And we all know that that is predominantly how
nurses are used.
The majority of interviewees were nurse ACPs employed in GP practices. Recruiting
participants from other professions and other sectors proved problematic. Participants
who were recruited from these areas suggested low response rates were perhaps due to:
AHPs not being regarded as ACPs, despite working to an advanced level, and can struggle
to acknowledge ACP status themselves; the perception that ACPs do not work in the
E6: It’s not my title, and my husband, who is a nurse consultant, he said, “You’re not advanced
clinical practice. That’s a nurse consultant role”. But actually, when I think about the four pillars
[…] this is bread and butter for me. I am an advanced clinical practitioner, but in some ways, I don’t
perceive it as that in my head [OT].
E4: So, advanced practitioners to me are NHS and GP-based, not private sector [care home manager].
Participants discussed a number of challenges in education and development
provision, for example, ensuring education courses are available that support and
underpin advanced skill development. The majority of participants said that undertaking
a formal programme of education specifically constructed to develop students to become
ACPs in primary care is essential. The introduction of ACP Master’sdegreeprogrammes
that align with the HEE ACP framework was welcomed by the vast majority of
interviewees. Those who had undertaken an ACP Master’s degree programme felt that
this had improved their critical thinking and decision-making skills, and “changed”their
W1: Master’s level study is to critique evidence that is out there […]Andit’smade
a difference to my practice. And it has changed the practitioner I am to when I started the
Masters –has changed.
When asked about their views on the quality of educational and professional development
programmes they had accessed, participants expressed a number of concerns. First, they
said that ACP study programmes offered by universities vary in quality, which they felt
impacts on the levels of care quality provided by ACPs undertaking these courses.
To address this, participants proposed that a standard ACP course should be offered by
E3: It needs to be absolutely standard […]. We talk about managing unwarranted variation in all
aspects of our care. I think this is no different.
Participants reported that quality depends upon courses’relevance to practice. Some felt
that current provision does not always address the advanced level needs for ACP practice.
They also proposed that clinical skills development is most effective when relevant,
practice-based approaches are embedded in education. Some participants suggested that
current provision lacks this, leaving ACPs unprepared for the demands of their role:
E8: The biggest issue is effective clinical development. Most courses fail to give this because
practice-based learning is often limited, time critical and therefore not always sufficient to give the
required depth of knowledge.
Participants also commented upon education provision regarding the leadership and
research pillars. Again, they suggested this needs to be relevant to their everyday work, and
to innovations and projects they would like to take forward. Participants felt that these
aspects are often omitted from courses that tend to be more theoretically based:
E2: It’s helpful to know where to go to look for project management skills and service development,
would make much more sense than a purely academic piece of research.
A significant concern for participants was the limited relevance of current ACP education
provision to primary care. A number of participants reported that current provision includes
courses that are adapted versions of ACP secondary care courses that are already in
existence. These participants proposed that if primary care ACP education is to be relevant,
valuable and engaging, it has to be developed specifically with primary care in mind:
C1: You need whoever is running the course to be able to understand primary care and be
able to see how you give exemplars of what works in primary care versus what works in
secondary care. And I think that’s been part of the problem is that primary care has been left
behind in training courses.
A major issue discussed was funding of education programmes. Participants said that while
funding for courses is available (e.g. from HEE), backfill needs to be funded to allow trainees
to be released from their existing practice roles to enable them to take advantage of learning
opportunities. Many participants stated that backfill costs prohibited the expansion of the
ACP role in primary care:
E3: The biggest challenge of developing ACPs is that people can’t afford to allow that person to
become supernumerary, to be learning. You can’t get funding for a workforce thing. It’s purely
about the academic qualification that they fund.
There were some instances where employers had negotiated with CCGs to provide backfill
funding. While this support was very much welcomed, participants explained that even
where funding for backfill is secured, it can be difficult to obtain because there is a dearth of
skilled staff to provide cover:
E2: It’s pointless saying to people “We’ll give you backfill. We can pay for backfill.”Because people
aren’t sitting about waiting to pop in and fill in a gap.
The inconsistency in the provision of CPD updates, in particular non-medical prescribing
updates, was referred to during interviews. Participants felt that a more standardised,
formalised approach to updates is required, and that updates should occur regularly to
ensure ACP practice is safe and up-to-date:
E9: Once you’ve got your qualification, there doesn’t seem to be much afterwards […] I feel like we
could do with more formal updates for non-medical prescribers. Just to make sure that we’re still
practicing as we should be.
Participants proposed that ACP development requires the support and supervision in
practice of allocated mentors/supervisors. They suggested that in order for mentors/
supervisors to provide adequate support, they need to be fully committed, and need to
understand what this role entails in terms of demonstrating, observing and assessing
practice, and the long-term commitment involved:
C1: They need to understand what that might mean. That they might need to sit in with the trainee
ACP while they’re practicing, as an observer. They may need to be there, being the person who’s
being observed. They need some ability as a mentor. And some understanding of the fact that this
is a two-year thing.
Some participants felt that supervision is not only about supporting clinical development,
but a means of providing support for staff coming to terms with a change in role, and the
uncertainty about professional identity that may bring:
W2: An aspect of clinical supervision, that is seen to be most important is the massive change that
goes on when you’re transitioning from nurse to ACP. We do nothing to support people at an
emotional and personal level, in how they go through the evolution of coping with the change from
being an ordinary nurse to an ACP.
Many participants stated that it is essential to obtain the support of practice education
facilitators who have knowledge and understanding about ACP development programmes,
are skilled at facilitating teaching/learning within practice, understand and can address the
logistical and organisational challenges involved in practice learning and can support both
students and mentors:
E3: There’s something about practice education facilitation, so you’ve got that cover. And thinking
about the relationship and support that management and mentors need as well.
Organisation and culture
All participants reported that organisational and cultural factors have a significant impact
on ACP development and practice. The pressure on services in primary care, together with
the GP recruitment crisis, is a driver for ACP recruitment. Some participants suggested
recruitment of ACPs to “fill GP gaps”can restrict ACPs’scope of practice to clinical
activities. These participants proposed that a hierarchical culture operates in primary care,
whereby GPs are perceived as business/practice/clinical leaders, and the only option to
manage complex clinical cases. Some participants said this leads some GPs to feel
“threatened”by ACPs, which can result in GPs’reluctance to allowing ACPs scope to work
at their full potential. They also said that this situation is unlikely to change unless GPs are
willing to change how care is organised and delivered:
C4: And there was loads of them that had seen a GP that actually could’ve seen an ACP nurse or
physio, or pharmacist. But I think the doctors don’t want to give up their role. So, there’sa
reluctance from GPs to change.
Other participants suggested the problem lies less with hierarchical culture,
andmorewithemployers’lack of understanding or recognition of the scope or
benefits of the ACP role in care delivery. These participants felt that until employers
are properly conversant with the scope of the role, opportunities to utilise its full scope
would be limited:
E8: There needs to be some focus on increasing the understanding and appreciation of ACP roles
across the wider system to ensure that the scope of the job is recognized.
Many of the factors influencing the development and practice of ACPs that were discussed
by participants concerned system-wide, organisational infrastructure challenges. For
example, cross-organisational ACP referral procedures are inconsistent leading to
inefficiencies in practice. While some NHS Trusts and departments accept ACP referrals,
others do not:
E9: Some of the barriers come from secondary care in some don’t like referrals from us. They like
referrals from GPs.
Participants working in the private social care sector and voluntary sector proposed that a
major difficulty in initiating development of ACPs outside of the NHS is the need for NHS/
GP medical support. They explained that the challenges of obtaining agreement for cross-
sector support in the current climate prohibit this development:
E9: I just don’t know it would be achieved. Who would be able to provide them with the relevant
support […] that’s where we, from a care home perspective, would really struggle.
A few participants proposed that wholesale organisational system change is required if
ACPs are to be developed to meet standardised capabilities, have standardised role
definitions, receive comprehensive support and practice to their full potential. This would
involve a move away from individual GP practice businesses to large primary care
employing organisations. The following interviewees proposed that the current GP led
system is too diverse, reactive and inconsistent to offer a standard quality service that is
both effective and efficient:
E3: We haven’t moved from general practice to primary care, and we have to move to primary care.
I go into every forum now to say if you don’t think of primary care as an organisation in a system,
that needs the same kind of logistical set up as big Trusts have –we’re finished.
During interviews, participants were asked how they became ACPs in primary care.
Although many suggested that there was an appetite for development opportunities,
the majority of participants said that there is no clear career pathway for ACPs in
the primary care sector. For many participants, career development was a reactive
process to address local need. For example, many were directed towards the role
specifically to address gaps in service:
W3: I’d worked in the practice for nearly 30 years, then at the time there was a shortage of GPs and
there was funding, so I was nudged in that direction.
Others had moved into primary care after long careers in secondary care. These participants
often commented that this move was a kind of “winding down”. One interviewee
“fell into the role”when looking for post-retirement opportunities:
E8: I fell into the role by accident, retired from an NHS role and actually through visiting my own
GP surgery and seeing the nurse there thought it would be interesting.
Phase 1 of the study indicated that in primary care, many ACPs are reaching or considering
retirement. In addition, the responses cited above show that the ACP primary care role may
not be perceived as a dynamic role, or a career goal in its own right. Many participants were
concerned that this would result in: gaps in the ACP workforce in the near future because
there is no structured succession plan; a depletion of other parts of the workforce as staff are
moved into ACP roles to fill that gap; staff who have “fallen into”ACP roles not having the
advanced level skills required to manage an ageing population with complex needs. Most
participants expressed the opinion that in order to address these problems, more needs to be
done to develop a clear career pathway. Many said that having the ACP framework was a
good start, but that other factors need to be considered too, for example, developing a
pathway requires an infrastructure, funding and organisational processes to facilitate skilled
backfill, and learning support in practice in order to provide a sustainable professional
development “flow”. Many participants stated establishing a career pathway and an ongoing
professional development “flow”would be best facilitated by a nationally recognised career
framework. They also suggested that currently, ACP level practice is the most nurses and
AHPs can expect to achieve in clinical primary care, but a formalised, standard national career
framework, which prescribes a career pathway, would enable development beyond ACP:
C5: At present once you are an ACP, you are perceived to be at the top of your clinical career path.
Surely we should be seeing this is the initial stepping point to progression as a “General Clinical
Practitioner”for those that want to progress. I would hope that one day these individuals are given
a career pathway to support this.
Findings from the study suggest that a number of factors influence the development and
practice of ACPs in primary care settings, and ACP professional identity. These are not
limited to access to, and quality of, education but reflect the need for a “systems thinking
approach”as findings demonstrate a need to address role definition, supervision/support
requirements, organisational infrastructure and culture factors and career progression, as
well as education. Table II summarises the findings of the study and highlights the
influencing factors (IN FACT framework) that should be considered if ACPs in primary care
to be effectively maximised at scale.
Fundamentally, findings from this study have identified that a major challenge for ACPs in
primary care is negotiating and navigating their professional identity, and their professional
boundaries and development, where there is a system-wide lack of understanding or
recognition of the scope or benefits of the ACP role in care delivery. This lack of
understanding may result from a perception of ACPs as “gap fillers”, and confusion, in the
absence of a standard definition, about what the remit of ACP actually is. Findings also
identified that AHPs and staff from the private and voluntary sector are less likely to be
recognised as ACPs, even if they have extended practice roles. This can impact in various
ways. ACPs working in GP practices suggested their practice is restricted and professional
boundaries are reduced. Their expectations of what ACP working is are therefore not
realised, nor are they working at their full potential –something which they found
frustrating. Their response reflects Hackman and Oldman’s role characteristic model
(Hackman and Oldham, 1980; Devaro et al., 2007), which proposes that such circumstances
impact on occupational identity and job satisfaction. The model supposes that job
satisfaction results from individuals’abilities to perform the work characteristics which
they perceive to be intrinsic to their role. The performance of expected characteristics
associated with any role increases job satisfaction because there is a link between
expectations regarding role and feelings of personal meaningfulness. When the actuality of
the role does not equate with expectations, then job satisfaction is diminished, and role
identity becomes uncertain. On the other hand, ACPs employed by the private and
voluntary sector, and those with AHP backgrounds, “internalised”the lack of
A Whole System Workforce Framework of INfluencing FACTors (IN FACT)
Standardised role definition and inclusive
Standardised capabilities and capability framework
Clearly defined practice remit, job title, job description
AHPs, private sector, social care sector, voluntary sector
inclusion and recognition
Access to/availability of quality
accredited educational and professional
development opportunities at the
Masters/APEL aligned to standardised capabilities and
Standardised, relevant courses that include a practice-based
Focus on PRIMARY CARE
Includes regular, formalised CPD updates
Support and supervision Support within practice for trainee ACPs
Culture and belief
Understanding support needs
Induction into the role
Supervision and support networks for ACPs
Induction into the primary care sector
infrastructure and culture
Support with accessing and understanding costs of ACP
Provision of backfill for practice and mentorship
Shift in organisational culture
System-wide recognition of the scope and benefits of the ACP role
Cross-organisational agreement to support ACP development and
practice (e.g. between NHS, private sector, voluntary sector, social
Move to a system-wide primary care organisational model
Career pathway National career framework for ACPs in primary care
Dynamic, attractive role
Structured succession planning
Avoid depletion of other parts of the workforce
Advanced skills for primary care
Professional development “flow”through the system
Develop beyond ACP level
Regular, formalised appraisals
IN FACT framework
understanding about their ACP status to the extent that they did not always recognise
themselves as ACPs. This may be a consequence of interpellation, defined, for example, by
Althusser (1971), as the process by which a social situation precedes or produces an
individual’s sense of their own identity. Only by changing the social situation, in this case by
clearly promoting ACP as inclusive and broad, can this be rectified.
Findings indicate other possible contributing factors to restrictions in ACP practice are
at play. For example, negotiating differing agendas generates a tension for ACPs,
particularly those working in GP practices. This group of participants acknowledged their
role in “freeing up GPs”, as intended by the “GP Forward View”. However, they also
proposed GPs can be reluctant to relinquish aspects of their role other than “routine”clinical
practices. It may be that some GPs resist any role overlap, as an incursion on their own
professional identity and boundaries. This can lead to the creation of a hierarchy of practice
whereby leadership, education, research and complex clinical practice become the remits of
medics, and the scope and career progression of ACP practice is restricted, and potentially
undervalued. Judge et al. (2000) suggest restricting complexity within occupational roles can
impact on individuals’self-concept. Complex activities are more likely to require and
encourage skill improvement, interest and innovation, aspects which promote feelings of
fulfilment and positive self-concept. Furthermore, ACPs undertaking restricted practice fails
to acknowledge the strategic plan (NHS England, 2015, 2019) to develop primary care and
out of hospital services to meet the changing demographics.
Organisational system change
Some participants argued for wholesale organisational system change if ACPs are to be
developed to meet standardised capabilities, have standardised role definitions, receive
comprehensive support, practice to their full potential and have opportunities for career
progression. These participants proposed radical system change, involving a move away
from individual GP practice and private businesses to large primary care employing
organisations, in which ACPs would work alongside a range of professionals. Robertson
et al.’s (2016) report on clinical commissioning for the King’s Fund, to some extent supports
this finding. The report proposes that effective, efficient primary care that is consistently of
a high quality, requires an integrated organisation of care delivery including “scaled up”
forms of care. In GP practice in England, scaling up is generally achieved via federation
working. In 2008, the Royal College of GPs published its plan for primary care federations.
In this plan, federations were viewed as a method of offering extended services, strengthen
links with other primary care services and redesign services to be closer to patients. There
was no mention of plans for ACP utilisation at scale. The NHS “Five year Forward View”,
proposed future care models including multi-speciality community providers (MCP). MCPs
offer federations the potential to integrate with community services to create a broader,
resilient type of general practice with a single whole population budget. Plans and
recommendations for the development of MCPs and federations recognise that they could
facilitate flexible and adaptable workforce models, and centralisation and standardisation of
workforce development (Connor, 2016; NHS England, 2016). However, these
recommendations do not make clear whether these new models should include plans for
ACP practice. In this study, participants who suggested the GP model was restrictive were
employed in federation and non-federation practices. This suggests that the utilisation of the
full ACP potential at scale is less about the size of the employing organisation, and more
about employment and workforce development strategies.
Access to professional development programmes
Findings suggest education level and professional registration can influence role identity
and development of ACPs. Professional registration and having a Master’squalification
were viewed as integral to being an ACP. This reflects Beddoe’s (2010) work, which
suggests professional registration and qualifications support standardisation of practice
and facilitate safe, effective care, but also generate professional capital, recognition,
understanding and value for the role from the perspectives of both the individual
practitioner, and the society in which they work. The question of registration has been the
subject of debate for several years. Critics of registration with professional bodies propose
it is unnecessary and unworkable, because ACPs are already registrants therefore do not
represent any greater risk to the public than non-ACPs (Barton et al., 2012a). In the
absence of national professional registration, East et al. (2015) propose local NHS
regulation. However, NHS-held registers wouldnotaccountforACPsworkinginthe
private and voluntary sectors.
While participants welcomed the advent of a requirement for a Master’s degree, some
proposed having a Master’s qualification in itself is not enough. This is because a tension
exists between being “educated to Masters level”,and“how staff are educated to Masters
level”. Lack of standardisation of programmes leads to differentials in ACP capability, but
also findings indicate that current Master’s education is not practice-based enough, in that
education (particularly research and leadership) focus on theory and philosophies that do
not sit well with practical project management/service improvement that are expected of
the ACP role. In addition, participants were concerned that ACP programmes do not
adequately address the requirements of primary care. While this can be detrimental to the
quality of primary care-specific competency development, it also suggests that primary
care is not acknowledged as an area requiring advanced practice skills in its own right.
According to Beddoe (2013), areas of practice are devalued where there is such absence of
For participants, supervision and support within the working environment are integral
to ACP competency development, but also to supporting a sense of role identity. Illeris
(2014) extended Mezirow’s (2000) work on transformational learning and argued that
learning and competency development are psychosocial processes, not simply cognitive
processes. As such, identity both influences, and is influenced by, interaction between the
individual and the social environment in which learning and development takes place. For
Illeris (2014), lack of this interaction can lead to a poorly developed sense of identity
resulting in practitioners learning “tasks”, rather than fulfilling “role”–in this case, clinical
skills rather than fulfilling the role remit as perceived in the ACP literature.
Some previous approaches include methods that may be useful in addressing these
factors. For example, the West Midlands ACP framework (HEE, 2015) has standardised
the ACP role across England’s West Midlands region via engaging all healthcare and
university stakeholders in the development and incorporation of the ACP role into
organisations. The West Midlands’model also acknowledges the benefits of
practice-based education, and supervision and support networks by integrating formal
clinical supervision and team support into its workforce development approach.
A difficulty with the West Midlands model, however, is that in aiming for standardisation,
paradoxically it is perhaps too generic, and in need of consideration and adaptation for the
primary care context. In this study, a major concern of participants was that current ACP
development approaches are grounded in secondary care approaches, and are not relevant
enough for primary care requirements.
Standardisation of programmes can be achieved through commissioning and greater
awareness, and use of, apprenticeships, although this would require aligning ACP study
programmes with national apprenticeship standards. The apprenticeship model could be
useful as a means to support provision of effective learning environments, as learning would
be practice-based, which participants proposed was the most effective method of ensuring
learning is relevant to their development needs. Also, contractually, apprenticeships would
commit the required resources to provide practice-based support and supervision that is of a
standardised, high quality. Apprenticeships do not on their own address some of the other
problems highlighted in the study, for example, lack of understanding about the role and
remit of ACPs, and difficulties in cross-organisational working.
Findings show that career progression opportunities for ACPs are limited and inconsistent,
and there is no clear ACP career pathway, or opportunities to develop beyond the ACP role.
Barton et al. (2012b) proposes that this is to be expected in circumstances where there is no
standard role definition, job title or job description. Findings indicate the lack of career
pathway can adversely influence professional identity and as well as professional
development, as the situation means staff often drift into the role reactively to “fill gaps”,or
take on the role as a means of “winding down”their careers. Bern-Klug et al. (2003) suggest
that a number of worker “types”exist, including “inheritors”–workers, such as some
participants in this study, who enter an occupation because they have inherited a position,
or because they have settled for any position. The authors argue that if an occupation’s
workers are primarily “inheritors”, then occupational status is lowered, and the occupation
becomes an unattractive employment prospect.
During the discussion, proposals have been suggested to address the requirements of the IN
FACT framework, but these may be insufficient, as none address the system in its entirety.
A potential whole system strategy could be the development of primary care workforce
development hubs, which are employing organisations funded by health education
commissioners (in England, this would be HEE), as a means to facilitate standardisation of
workforce development. In this model, the hub would take on responsibility for developing
capacity for practice-based learning and assessment, and ongoing supervision of ACPs, both
during formal learning programmes and upon qualification. The team would comprise of
ACPs working as workforce development leads/practice educators, GP vocational training
leads and practice placement facilitators. This ensures that appropriate skills resources are
readily available, enabling members of the team undertaking ACP study to have time to
engage fully with the course. This team would provide the infrastructure to develop practice
placements in primary care; and support, supervise and assess students in practice on a wide
range of programmes including ACP with backgrounds in nursing and AHP. It may be
beneficial to allocate student ACPs to hubs, rather than individual practices or organisations.
This would enable students to experience a range of primary care placements, maximising
opportunities to develop confidence and competence in working across an integrated care
system, and could maximise ACP development in primary care at scale. This would also
alleviate some of the pressures and challenges faced by employing organisations regarding
ongoing provision of a learning environment and backfill for employees who are both
studying and working as clinical practitioners within that environment.
In terms of professional registration, if ACP capabilities are clearly defined and able to be
evidenced, voluntary local registration is possible and could be managed at regional level by
the hubs. This would inform future workforce planning and development, and could
encompass all ACPs working in primary care, including independent sector workers.
Findings suggest it is imperative that a universally accepted definition of ACP is
implemented, and a National Career Framework for primary care ACPs is introduced. Using
the primary care hub approach discussed above would support a professional development
“flow”through the primary care workforce system, which could facilitate future workforce
succession planning, and the development of a workforce skilled in managing care
specifically in the primary care setting.
The debate about how best to address the challenges of an overloaded GP workforce,
improve patient care, and facilitate organisational efficiencies, remains a prominent
political, health and social care and economic theme. Previous literature suggests inclusion
of ACPs in the primary care workforce can contribute to the mitigation of these challenges,
but standardisation of role and competency are required if the initiative is to be effective.
To date, proposals to address these challenges have been insufficient on their own.
Utilising a workforce development approach to explore ACPs’perceptions and experiences
of ACP identity and role development has led to the generation of the Whole System
Workforce Framework of Influencing Factors (IN FACT), which lays out the issues that
need to be addressed if ACP potential is to be maximised in primary care. This paper offers
suggestions about how IN FACT can be addressed. However, as the study findings
are based on the responses of a small number of participants located in the North of
England, recommendations offered need to be piloted, and evaluations undertaken to
measure impact on a range of outcomes including practitioner, patient and practice
outcomes and cost benefit analysis.
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