The role of governance in advanced practice

What is advanced practice? 

Advanced practice is a level of practice where a practitioner has demonstrated their ability to work autonomously at a high level (level 7/ Masters level) across all four pillars of advanced practice. The four pillars of advanced practice are: clinical practice, leadership and management, education, and research. Advanced practitioners (also commonly referred to as advanced clinical practitioners, or ACPs) are prepared via designated programmes of education and training, such as an MSc advanced clinical practice. Read more about advanced practice on our web page. 

The benefits of advanced practice 

Research shows that advanced practice roles have a positive impact on healthcare services and by ensuring that they are deployed effectively can increase the impact in the future (Stewart-Lord et al., 2020). The successful employment and deployment of advanced practitioners is important in maintaining a productive workforce, it can advance access to care and improve patient outcomes. This can be challenging as historically there has been insufficient guidance to enable consistent implementation of advanced practice in NHS organisations. In recognition of this, Health Education England, now NHS England, introduced the Multi-professional Framework for Advanced Clinical Practice in England (2017).

Additionally, NHS England’s Centre for Advancing Practice recently published the Advanced Practice Governance Maturity Matrix (2022) and updated this in 2023. This tool was designed to help NHS organisations self-assess progress on effectively implementing advanced practice, and as a prompt to identify areas where improvements can be made.

Additionally NHS England’s delivery plan for recovering urgent and emergency care (2023), recognised the need to increase the number of advanced practitioners in priority areas. The plan emphasises the value advanced practitioners add to the NHS workforce. By enabling clinicians to take on expanded roles, supporting the standardisation of same day emergency care, and helping make the most effective use of multi-disciplinary teams. 

Assessing and improving standards  

Using the governance maturity matrix  

The matrix encourages discussion and constructive challenge, as well as internal and system-wide collaboration to support the consistent implementation of advanced practice in the NHS. Using the matrix is not mandatory, but we encourage employers to embrace the tool and connect with colleagues who have made progress with assessing and improving outcomes for advanced practice. The matrix can be used alongside other resources such as NHS England's multi-professional framework for advanced clinical practice in England (2017). 

The matrix is designed to be used across all NHS settings including acute, community, mental health and primary care. It is recommended that only those with responsibility for advanced practice within their organisation complete the matrix to inform their local advanced practice implementation strategy. It is useful to ensure that there is no duplication of this work elsewhere within the organisation to avoid confusion.  

To ensure that local strategies align (where possible) and work towards overall system-wide aims, it is beneficial to collaborate and share ideas with your ICS and other trusts.

How NHS organisations can benefit from using the maturity matrix 

If used correctly and in collaboration, the maturity matrix can:

• Act as a developmental activity for organisations/teams by helping them identify areas where they are doing well, and where to make improvements.  
• Encourage employers to consider eight domains (discussed below) that enable effective advanced practice implementation. These eight factors were identified through a scoping exercise that led to the development of the matrix. 
• Foster discussion and influences change. It aids the development of a strong business case for improvement. 
• Support health and care providers to put anticipatory governance arrangements in place and formulate an effective strategy. 
• Encourage organisations and teams to review the effectiveness of their approach regularly. 
• Help to inform the advanced practice strategy and policy in NHS organisations as well as  the strategic action plan in trusts. 
• Enhance the positive contribution of advanced practice roles towards workforce development and deployment, service delivery, and improving patient care.

The eight domains  

The matrix is divided into eight domains, which system leaders, employers, allied health profession leads and line managers can assess their progress against. This will indicate whether they are making either early progress, substantial progress, or are mature in the effective implementation of advanced practice within their system/organisation/team.

Gaining support from, and collaborating with regional faculties for advancing practice can enable organisations to use the matrix most effectively. It is also helpful to set up or join existing networks of colleagues who have responsibility for overseeing advanced practitioners as it creates a space to work together, generate system level plans and ensure a consistent approach. For example, advanced practitioner leads in an integrated care system can collaborate, network and share examples of good practice and how they have completed the matrix.  

Governance of advanced practice roles 

The effective implementation of your advanced practitioners starts with understanding your workforce data. Determining how many, where and what specialities are working in the organisation is key. This may involve some scoping and redesign of the way employee data is recorded, for example, on the electronic staff record (ESR) system, where applicable.  Working with relevant stakeholders to ensure that staff are consistently assigned to the correct occupation codes can help with this.  

Leadership at all levels  

Robust organisational structures, support and guidance can enable effective leadership; which is vital for advanced practice. Leaders of advanced practice should be identified and must have a clear understanding, and preferably experience, of advanced practice across all four pillars which include clinical practice, leadership and management, education, and research. Ideally, job descriptions and job plans for advanced practitioner leads should reflect the requirement for extensive knowledge and experience of working as an advanced practitioner, and they should encourage colleagues to fulfil all pillars of their roles.

We recognise that some leaders of advanced practice may not have previous experience in an advanced practitioner role. It is recommended those individuals link with their respective regional faculties for advancing practice to gain insights into challenges and developments in advanced practice. 

Advanced practitioner leads should be readily accessible and form channels of open communication across the organisation, valuing and acting on feedback from patients and staff. Ensuring there is a representative at board level who can advocate for effective advanced practice implementation can help ensure it stays as a priority on the workforce agenda. 

Building advanced roles into the workforce 

NHS organisations and primary care training hubs must regularly and actively identify and evaluate the impact of advanced practitioners in their organisation. They should consider how they will gather and utilise data to demonstrate impact on service provision, access, patient outcomes, pathways, and the teams they serve. This will help line managers demonstrate the value for money that advanced practice provides, helping to build a business case for the development of advanced practice in other areas. 

The planning and recruitment of advanced practitioners across all settings should map to wider workforce plans and reflect the diversity of staff and the local population. Furthermore, employers must work closely with, integrated care systems, regional faculties for advanced practice and higher education institutions to collectively fulfil the local workforce needs with the aim of improving local health inequalities. Working at a system level can lead to resources being pooled, help to improve consistency of practice, direct the professionals to where the patient’s needs are, and ultimately improve patient care. 

Building a business case and funding 

Business cases for implementing advanced practitioners should reflect the true cost of training, implementation, clinical/management placements, supervision and the future requirements of the role. The approach for writing business cases for the implementation of advanced practitioners should be consistent across an organisation, and preferably a system, with standardised narratives available to support those writing it. 

The costs and implications associated with career development and future roles in academic, clinical, leadership, and education roles should be considered. Business cases should demonstrate robust evaluation that showcases the true impact of advanced practice across the system/organisation. It should support the need for expanding the workforce or developing their skills. Where possible, employers should aim to secure long-term investment in the advanced practitioner workforce, as opposed to a single cohort, although it is appreciated that a board may wish to see the benefits before committing to further investment. Getting leaders on board with your initiatives, working at a system level and pooling resources can strengthen business cases. Think about how you can demonstrate the improvements and benefits that advanced practice can bring to the organisation.  

Advanced practice training and assessment  

Advanced practitioners across the organisation should undertake standardised, equitable, supported, resourced training and assessment. Assessors should be trained, capable and familiar with relevant assessment tools. This should help ensure advanced practitioners are confident, capable, and feel safe to practice within their field. They should be supported to follow national, regional, and local accreditation processes, including credentials and other area-specific capability frameworks (where these are relevant to service requirements and the role).    

Assessment should be comprised by a defined structure of summative assessments and gateways that evidence progression towards endpoint capability, credentials and recognition. Advanced practitioner leads should have regular discussions with university advanced practice programme directors, employers and training hubs to encourage targets to be better aligned. It is also important to emphasise the recommendation for advanced practice education programmes to be accredited by HEE’s Centre for Advancing Practice. This collaborative approach helps meet the needs of the employer and the local population more effectively. For example, creating a collaborative on-boarding process of trainee advanced practitioners, where both the employer and Health Education Institute (HEI) have oversight of the process can help troubleshoot any problems early and streamline the process.  

Regularly assessing capabilities of your advanced practice workforce through the annual appraisal process can help identify any skill gaps and areas for the development of your workforce. You can read more about this in the agenda for change terms and conditions of service handbook (or equivalent for those not on these terms and conditions). 

Clinical practice 

Advanced practitioners should have the right level of clinical capability to be able to practice safely. Clinical governance and assurances should ensure staff feel safe to practice in their scope of practice and professional registration requirements. Employers in turn must take all steps to support their practitioners to practice safely in order to provide the best patient care.  

Part of enabling effective clinical governance is through practitioners ensuring their portfolios of competence and capability are regularly mapped and maintained. It should represent the employees’ journey from trainee to retirement and support lifelong learning and revalidation (if appropriate). Furthermore, systems, policies and protocols should be representative of the entire advanced practice workforce, using language that is inclusive of all specialities.   

Systems/organisations/line managers can take steps to facilitate better public understanding and trust in the advanced practice workforce. By working with their communications departments to run campaigns that raise awareness about the role of advanced practitioners and highlight their high level of clinical understanding and competence for their colleagues, patients, carers and the general public. This can promote better team working across professions and help patients better understand advanced practise, so they are happy to be seen by the right professional at the right time. 

Supervision  

Employers should have robust organisational governance for the supervision of training and developing advanced practitioners. Supervisory practices should align with the standards set out by HEE’s Centre for Advancing Practice. Employers should consider how they will ensure sufficient supervisory capacity, as well as effective support, training and development for supervisors.  Systems/organisations could consider creating a database of educational supervisors to ensure all supervisors hear about training opportunities from the likes of HEE, royal colleges and other providers of training. Creating a distribution list can help easily share information and training opportunities. 

Advanced practitioner continuing professional development (CPD) 

As part of the yearly appraisal process the practitioners’ continual professional development aims should be discussed to ensure they are developed and retained. 

Advanced practice should not be seen as the endpoint in an organisation. Career progression pathways should be clear and accessible across clinical academic, leadership, clinical practice, and education careers. Development should be centred around all four pillars of practice and there should be equal access to development opportunities. Appraisals can be a useful opportunity to identify future aspirations and grow the advanced practice workforce.