Developing the role of the Assistant Practitioner

Nurse checking machine

25 / 10 / 2010

Calderdale and Huddersfield NHS trust has used this framework to develop the role of the Assistant Practitioner to address national healthcare priorities, and improve patient care. Its effectiveness has been recognised across the country - and internationally. It has been used to review the shape of the workforce in many organisations since it was established.

We went to meet colleagues at Calderdale to find out about: 

The organisation
What is the Calderdale Framework?
How they did it
Results and next steps
Top tips for trusts
Further information and contacts 

The organisation

Calderdale and Huddersfield NHS Foundation Trust provides healthcare for more than 435,000 people across Calderdale and Kirklees. It runs the two main hospitals, the Huddersfield Royal Infirmary and Calderdale Royal Hospital and some local community services. The trust continues to modernise and invest in health services to deliver patient focused patient care.

What is the Calderdale Framework?

The nationally acclaimed Calderdale Framework is a quality assurance framework developed and implemented in the Rehabilitation directorate at Calderdale and Huddersfield, by Rachael Smith and Jayne Duffy (Smith & Duffy 2010). It is a transformational tool which can be used to improve the way people work. It provides a clear and systematic method of reviewing skills mix, role and service design to ensure safe and effective patient-centred care.

The Framework addresses issues such as cultural change, risk, educational requirements (including work-based learning) and governance arrangements required for the new roles.


In 2009, Calderdale and Huddersfield NHS Foundation Trust was invited by Skills for Health to be an early implementer site for the Allied Health Professions Career Framework. The trust used its own Calderdale Framework to establish an assistant practitioner role in practice. The Framework was applied in two therapy teams; the MacMillan Cancer Rehabilitation Team and the Early Orthopaedic Discharge Team. 

The process of implementing the Calderdale Framework led to the development of competency based training programmes for staff, and two new qualifications were developed in partnership with their higher education institute (HEI), helping to assure quality and safety for patients, whilst maximizing workforce capability. Clear governance practices including clinical supervision and a local register of competence were also established.

How they did it

The process consisted of the following seven stages (reproduced with permission of copyright holders):

1.  Awareness raising

focused on staff engagement to ensure managers and clinical staff were fully informed and aware of the process, context and benefits of the Calderdale Framework. At this stage cultural issues, which may otherwise block progress, such as resistance or reluctance to delegate and/or skill share by clinicians can also be addressed. ‘Champions’ are also recruited at this stage. These team members play a crucial role in keeping the process ‘live’. The Standards for Assistant Practitioners were also included in this session to clarify expectations of all team members as was reflection back onto HSPC codes of conduct around competence for registered practitioners, which recognises competence changes subject to the context of work.

2. Service analysis

focused on potential to change. This required frontline staff to identify all the functions of their service, break these into tasks/skills and consider who currently undertook each area.  Potential changes for improved productivity and quality were explored, and clinical staff took ‘time out’ to reflect on whether they were using their skills to best effect. This information was reflected back with the question “does this meet our service users needs now but also in the future?” taking into account national and local drivers. The collection of baseline data was gathered at this stage of the project.

3. Task analysis

focused on risk management. This stage involved analysing the tasks for suitability to delegate and /or skill share, based on assessment of risks using a decision table. This facilitated open, objective discussion with clinicians regarding possible risks and benefits associated with an Assistant Practitioner undertaking tasks previously in the domain of the registered practitioners. This leads to clinical consensus around the scope and practice of the Assistant Practitioner role within each team. 

4. Competency generation/Mapping to National Occupational Standards (NOS)

focused on quality. Agreement was reached on which tasks to delegate, allocate and share, with input from clinicians who identified the relevant performance criteria to form competencies. These local competencies provide evidence to meet National Occupational Standards (NOS), which can be used for academic accreditation. 

5. Supporting Systems

focused on governance. This step ensured the management of the risks associated with new ways of working. It ensured an explicit understanding of the scope of practice for each role within the service and provided quality assurance, risk management and ongoing staff development. Clinical supervision, reflective practice and robust communication were key to achieving this. 

6. Training

focused on staff development.  All registered staff were trained to ensure they understood how the competencies were derived and what their Assistant Practitioners were competent to do.  Assistant Practitioners were trained to meet the competencies and all staff were trained to understand the communication systems. The work-based competency training was accredited via externally verified APEL with the University of Bradford. 

7. Sustaining

focused on embedding and monitoring. This involved embedding the competencies. Job descriptions were standardised and trainee Assistant Practitioners explicitly helped to understand their responsibility to meet the Skills for Health (SfH) standards. Registered staff are integral to supervision and mentoring as well as training. Return on investment evaluations is also ongoing.via the induction process and staff personal development reviews which are monitored by regular audits.

© Rachael Smith & Jayne Duffy. All rights reserved

Results and next steps

Applying the framework at Calderdale and Huddersfield NHS FT resulted in the development of a competence based framework, where Assistant and Advanced Practitioner roles were introduced to support other staff. 

9 More senior staff
8 Consultant practitioners
7 Advanced practitioners
6 Senior practitioners
5 Practitioners
4 Assistant practitioners
3 Senior assistants/ technicians
2 Support workers
1 Initial entry-level jobs

Calderdale and Huddersfield worked closely with their local HEI (University of Bradford) to develop training courses for support workers to develop their skills and competences.  The courses are based on Skills for Health's Code of Conduct and Minimum Standards for Support Workers. They focus on aspects which are fundamental to the provision of patient centred care.

Band 3 workers can take the Certificate of Continuing Education in Professional Support. Workers already at Band 4 can progress to advanced practitioner by taking the Certificate of Higher Education in Professional Support.

As of October 2013, there were 25 Assistant Practitioners in post across the trust in the Therapy and Rehabilitation Directorate. They are now working across health and social care, which has been challenging to implement, but extremely positive for the patients benefiting from the new type of working. The staff in the scheme also gain from the opportunities it gives them. 

Maureen Knight joined the trust at Band 2, and as a result of the application of the Calderdale Framework completed the competence based learning to become an Assistant Practitioner at Band 4. She is a valuable, experienced member of the Macmillan Rehabilitation Team, working within the field of Physiotherapy and Occupational Therapy. She now has a Certificate of Higher Education, a formal qualification which evidences her fitness to practice. Asked about her experience, she said,
" I found attending University somewhat daunting, having never been in that environment, and it took some time to get used to the academic expectations of learning, for example writing assignments, learning how to reference, researching articles and enhanced IT skills…….  However, I found I was able to rise to the challenge, complete what was required and successfully pass the course with a Distinction.  Having graduated fills me with a great sense of satisfaction, both personally and professionally, and work based learning has proved a positive experience for me."

The Trust's Early Orthopaedic Discharge Team service has realised a cost benefit from the introduction of Assistant Practitioners in the team, as they have reduced the burden on the Physiotherapists and Occupational therapists, and on call costs have significantly reduced since their introduction.

By carrying out pre and post implementation analysis the directorate has also been able to identify the following added benefits:
• A reduction in staff sickness absence 
• A reduction in patient complaints

Since it was introduced, as well as bringing about significant benefits for the trust which developed the Calderdale Framework, numerous other organisations across the UK have used it to review the shape of their own workforces, making them more efficient and able to provide better patient care. The Local Education and Training Board (LETB), Health Education Yorkshire and Humber has commissioned the tool as a resource, free at the point of use for all NHS organisations in the region.

The Calderdale Framework has also been commissioned as the workforce tool of choice for the Queensland Health Board in Australia, showing its universal applicability. Randomised controlled trials just emerging are demonstrating some positive outcomes from its application.

Top tips for other trusts

  • Set clear aims/objectives 
  • Set milestones/deadlines 
  • Top down and bottom up approach is most effective as clinicians must be involved and empowered and managers need to support and lead the change 
  • 'Sell' the positives – for all staff and especially patients (this process leads to building the team around the patients needs).
  • The process fits well with ‘Better for Less’.
  • Link use of The Calderdale Framework to other productive initiatives - so it becomes part of ongoing service improvement.
  • Keep stakeholders up to date and celebrate the successes.

Further information and contacts

Rachael Smith /Jayne Duffy
Calderdale Framework leads
Telephone: 01422 317977

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