Advanced Clinical Practitioners

Nathan HumphriesPhysiotherapist

My Journey / Background• 1999 - qualified as a Chartered Physiotherapist, specialising in musculoskeletal outpatients from 2003• 2006 - commenced a split role 50% in physiotherapy musculoskeletal outpatients and 50% in the Emergency Department, initially exclusively seeing musculoskeletal presentations with the Emergency Nurse Practitioner team.• 2007 - qualified in the management of Minor Injuries and in 2011 Minor Illness• As a Physio also needed to become competent in nursing skills such as venepuncture and cannulation • 2013 - Joined the ED ACP team

What is an Advanced Clinical Practitioner (ACP)?• An ACP is a clinician who is trained to see and autonomously treat any patient of any age across the complete acuity spectrum dependent upon specialty. • This includes those patients attending with minor problems, through to those presenting with major illnesses and on to those requiring life-saving interventions within a specific service• They are experienced nurses / AHP’s who undertake supervised clinical practice whilst undertaking a clinically focussed Master’s Degree•Once trained and experienced – they will work at medical Middle Grade level and above

Development of the ACP Role at Heart of England Foundation Trust • Introduced in January 2006 in the Emergency Departments (ED) because of current and anticipated shortfall in medical staffing. •More recently introduced into Intensive Care, Critical Care Outreach, Acute Medicine, Elderly Care and are about to be launched across most specialities • In the ED it has now been proven that ACPs can work at the level of the senior decision maker• Long term investment required (additional financial, educational, teaching, mentorship, supervisory commitment)

Patient’s Understanding of the Role• For most lay people, ACP’s will look and sound the same as a Doctor. • They are trained to perform examinations, diagnose, investigate and manage patients in the same way. They form an integral part of the Consultant’s team.• Their uniforms and name badges identify their role but patients often do not understand what it means. The ACP should be happy to identify and explain their role as part of the consent to treat process.

The ACP training contract• 2 year training contract – centrally funded. It is then the responsibility of the individual directorate to fund the role•Governance arrangements – mirrors Gold Reference Guide for Postgraduate Specialty Training in the UK • Band 7 to Band 8a at around 2 years• Full funding for 3 year MSc Advanced Clinical Practice at Warwick University Medical School• 80% clinical / 20% non clinical split • ACP Faculty with Clinical Director and ACP Consultant leads

Heart of England Foundation Trust ©ACP Development Phases 1 - 3

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CLINICAL EXAMINATION SKILLS (CES) &CLINICAL DIAGNOSTICS AND INTERPRETATION (CDI)

Clinical supervised practice by senior cliniciansSupported by Consultant Educational SupervisorEnd of module assessments: CES - 71 Patient entries in clinical portfolio/ OSCEs/ Assignment CDI - 10 Patient entries in clinical portfolio/ OSCEs/ Assignment

Standard - MSF 3600 peer appraisal to highlight suitability of tACP to the EM environment Tran

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ASSESSMENT

Acute Care Assessment Tool ACAT(a) – 5 unseen patients across the age and acuity spectrum (must include at least 1 child, 1 Resuscitation case)

On successful completion of all elements the Educational and Clinical Supervisor’s Report is submitted to ACP Faculty for consideration of tACP to full ACP status

Clinical - MSF 3600 peer appraisal that focuses on clinical knowledge, skills & competences

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INTRODUCTION TO EM APPROACH

Understanding of EM processes and exposure to all areasHow to ‘take a history’ and how to ‘examine’Opportunity for the ACP Faculty to determine knowledge, skills & competencyShadow seniors and focus on clinical examinationUndertake junior medical training courseClinical supervised practice by ED senior cliniciansSupported by Consultant Educational Supervisor and Senior ACP Clinical MentorRepeated opportunity to practice history taking and examination skills

Heart of England Foundation Trust ©ACP Development Phases 4 – 6

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Consolidation of ACP training - needs senior review for complex cases only

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Mandatory completion of Adult clinical portfolioSpecialist module(s) in clinical practice e.g. Minor Injury Course, Elderly Care CourseMandatory completion of Child clinical portfolioAdvanced Life Support Training (ALS, APLS,ETC) Research Methods module – develop research proposalCompetent to work in ALL clinical areas

Clinical - MSF 3600 peer appraisal that focuses on clinical knowledge, skills & competences

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Demonstrating leadership by giving “senior” clinical opinion, mentor and appraise tACPs’

Competent to lead in ALL clinical areas

Competent to provide MG support within the ED and Clinical Adjacencies

Completion of additional skill-set incl. USS

Clinical - MSF 3600 peer appraisal that focuses on clinical knowledge, skills & competences and maps to ACAT (b) – MRCEM equivalent

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Completion of NHS Leadership Programme

Developing Senior MG Management competency and completion of a clinical management portfolioEvidence of structured training report Mastery of procedural competencesSee >2000 cases annually (10% are cases in the resuscitation room)Submission of comprehensive Clinical, Educational and Professional Portfolio to ACP Faculty

Clinical - MSF 3600 peer appraisal that focuses on clinical knowledge, skills & competences and maps across to ST6ACAT(c) – FRCEM equivalent

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Consideration of Senior ACP for full Consultant ACP statusAnnual Clinical & managerial - MSF 3600 peer appraisalCPD requirementsClinical component Research & audit componentService and practice development with significant contribution of tENP and tACPs through phases 4-6

Benefits of ACPs •More permanent workforce – more likely to sustain innovations and improvement momentum• A blended workforce who are highly skilled • Additional opportunities regarding workforce planning• Reduces the need for ‘system relearning’• Less reliance on external locums (variability)•Demonstrated to make fewer clinical mistakes and prescribe more safely than a transient workforce or MG equivalents • Retention and progression of talented non medical workforce• Able to treat patients across the age and acuity spectrum

Challenges • Financial challenge• Lack of understanding around accountability and responsibility of professionals allied to medicine• ‘Burying heads in sand’•Doing nothing is VERY costly in most Trusts•How do we ensure there is a disinvestment in medical posts (i.e. unfilled posts, locums)

Future •Need to THINK OF THE CLINCIAL WORKFORCE AS A WHOLE AND THINK DIFFERENTLY and design a structured developmental pathway across disciplines and throughout the region – HEWM •Why?

• A well trained complementary workforce is safer at every level• Confidence in the role from other disciplines • Controlled expansion as opposed to uncontrolled

proliferation of ‘advanced’ roles • Standardised education, supervision and support across

specialities and disciplines• We can begin to consider different workforce solutions

in different localities, explore new options, and to consider region wide commissioning of training.

Thanks for Listening