Are advanced clinical practice roles in England’s National Health Service a remedy for workforce problems? A qualitative study of senior staff perspectives

Abstract

Objective A major issue facing all health systems is improving population health while at the same time responding to both growing patient numbers and needs and developing and retaining the health care workforce. One policy response to workforce shortages has been the development of advanced clinical practice roles. In the context of an English national policy promoting such roles in the health service, we explored senior managers’ and senior clinicians’ perceptions of factors at the organization level that support or inhibit the introduction of advanced clinical practice roles. The investigation was framed by theories of the diffusion of innovation and the system of professions. Methods We conducted a qualitative interview study of 39 senior manager and clinicians in 19 National Health Service acute, community, mental health and ambulance organizations across a metropolitan area in 2019. Results Small numbers of advanced clinical practice roles were reported, often in single services. Four main influences were identified in the development of advanced clinical practice roles: staff shortages (particularly of doctors in training grades) combined with rising patient demand, the desire to retain individual experienced staff, external commissioners or purchasers of services looking to shape services in line with national policy, and commissioner-funded new roles in new ambulatory care services and primary care. Three factors were reported as enabling the roles: finance for substantive posts, evidence of value of the posts, and structural support within the organization. Three factors were perceived as inhibiting developing the roles: confusion and lack of knowledge amongst clinicians and managers, the availability of finance for the roles, and a nervousness (sometimes resistance) to introducing the new roles. Conclusions While the national policy was to promote advanced clinical practice roles, the evidence suggested there was and would continue to be limited implementation at the operational level. Development scenarios that introduced new monies for such roles reduced some of the inhibiting factors. However, where the introduction of roles required funding to move from one part of a service to another, and potentially from one staff group to another, the growth of these roles was and is likely to be contested. In such scenarios, research and business evidence of relative advantage will be important, as too will be supporters in powerful positions. The paucity of publicly available evidence on the effectiveness of advanced clinical practice roles across the specialties and professions in different contexts requires urgent attention.

Integration of a clinical pharmacist workforce into newly forming primary care networks: a qualitatively driven, complex systems analysis

“… 5–7 This reflects a broader task shifting to ‘mid-level’ professionals who are educated and trained to a level where they can undertake some of the activities of GPs and specialists within a prescribed scope of practice. 7 8 In primary care, some GP work tasks and responsibilities have shifted to nursing staff 5 and, more recently, clinical pharmacists. 6 9 Such developments occur within ongoing contexts of reorganisations, funding constraints and other pressures.…”

“…Clinical pharmacists are a key example of a ‘mid-level’ professional group. 7 8 Historically, pharmacists in the UK have mainly operated in secondary care hospitals or in community pharmacy, providing prescription dispensing services and, more recently, over-the-counter advice. 21 Numbers of pharmacists in GP practices increased during the 1990s via the GP Fundholding scheme and through the 2000s, but the absence of a national workforce strategy resulted in significant diversity, in terms of numbers and roles, across GP practices.…”

“…Reforms to this set-up have included attempts to enhance the role of GPs in healthcare commissioning and new models of service delivery that have transferred services out of hospitals into primary care 2–4. There have also been efforts to address shortfalls in the numbers of GPs and meet new healthcare challenges, including facing the increasing demand and complexity of patient needs, through the integration and development of new primary care roles 5–7. This reflects a broader task shifting to ‘mid-level’ professionals who are educated and trained to a level where they can undertake some of the activities of GPs and specialists within a prescribed scope of practice 7 8.…”

“…There have also been efforts to address shortfalls in the numbers of GPs and meet new healthcare challenges, including facing the increasing demand and complexity of patient needs, through the integration and development of new primary care roles 5–7. This reflects a broader task shifting to ‘mid-level’ professionals who are educated and trained to a level where they can undertake some of the activities of GPs and specialists within a prescribed scope of practice 7 8. In primary care, some GP work tasks and responsibilities have shifted to nursing staff5 and, more recently, clinical pharmacists 6 9.…”

“…This study presents a qualitative investigation of the early integration of a clinical pharmacy workforce into newly forming PCNs. Clinical pharmacists are a key example of a ‘mid-level’ professional group 7 8. Historically, pharmacists in the UK have mainly operated in secondary care hospitals or in community pharmacy, providing prescription dispensing services and, more recently, over-the-counter advice 21.…”