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 (HEE) introduced the Multi-professional Framework for Advanced Clinical Practice in England (2017).
Additionally, HEE’s Centre for Advancing Practice recently published the Advanced Practice Governance Maturity Matrix (2022). 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 HEE’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.
You will need to download a copy of the matrix before editing the document.
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).
Resources to help you with training and assessment:
HEE’s readiness tool allows trainee and aspiring advanced practitioners to self-assess their readiness for advanced practice training, and areas they may need further training in.
Read HEE’s guidance on of how credential development, delivery and take-up can increase advanced practice capability and capacity.
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.
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 collages and other providers of training. Creating a distribution list can help easily share information and training opportunities.
Resources to help you with supervision:
HEE’s supervisor readiness tool allows advanced clinical practitioners to self-assess whether they are ready to take on supervisory responsibilities.
HEE’s workplace supervision for advanced practice guidance outlines the seven fundamental considerations which underpin supervision in advanced practice.
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.
NHS Employers: Advanced and Enhanced Practice web page.
Health education England (2017) Multi-professional framework for advanced practice in England.
Council for healthcare regulatory excellence (2009) advanced practice: Report to the four UK health departments
Hardy, M. (2021) Advanced Practice: Research Report
National Health Service (2019) The NHS Long Term Plan
Health Education England (2022) Advanced Practice Workplace Supervision: Minimum Standards for Supervision
Health Education England (2021)Signpost for Continuing Professional Development
An introduction to the Governance Maturity Matrix
Our first webinar took place on Monday 3 March where we heard our speakers explore the current context of governance of advanced practice and give insights into using the matrix. Speakers included, the founder of the matrix, James Pratt, lead advanced clinical practitioner, Nottingham University Hospitals and Dr Julian Barratt, lead for the centre of advancing practice, Health Education England.
Watch the webinar recording below.
Using the Governance Maturity Matrix as an assessment tool
On Tuesday 28 March, this webinar showcased several case studies from trusts on how they have assessed their progress against each of the matrix domains. Speakers demonstrated how they collaborated in a community of advanced practitioner leads to assess progress in an ICS setting. We also heard from a community based and acute trust on the key challenges and enablers for effective governance of advanced practitioners.
Watch the webinar recording below.
Governing advanced practice: looking ahead and addressing the challenges
Now it’s time to take action and face the challenges you’ve identified head on. This webinar from April 24 will help you do just that. You will hear the journey of a trust who has made significant progress with governing advanced practitioners, using the governance maturity matrix to guide them. You will hear about how they looked ahead and formulated sustainable solutions.
Watch the webinar recording below.
Laura Dilley, lead advanced clinical practitioner, North West Anglia NHS Foundation Trust
We used the Governance Maturity Matrix as a sense check for the enhanced and advanced practice project plan and strategy. The assessment was carried out by the trust lead advanced clinical practitioner, who is familiar with individual roles and processes, as well as the wider Trust governance processes. A variety of stakeholders were consulted, including our Trust leadership teams, divisional leadership and advanced clinical practitioners themselves.
We used the matrix in to assess the Trust’s progress against our project plan. It helped us to provide a clear visual demonstration of the substantial progress that the Trust had made from January 2022 until March 2023, which was shared in the Non-Medical Workforce Board Report.
Shraddha Sharma, clinical placements and education lead -advanced practice, Cambridgeshire and Peterborough NHS Foundation Trust (CPFT)
The governance matrix was used initially by clinical placement and education lead for advanced practice to map the organisation against the eight domains.
This highlighted the need for Advanced Practice corporate lead post which led to a paper being presented to people board in the Trust.
The governance matrix also emphasised the effectiveness of the collaborative working across the region. For example, CPFT along with North West Anglia NHS Foundation Trust are working on series of webinars around Advanced Practice to increase awareness and share the national standards with stakeholders in our Trusts and regions.