Advanced Nurse Practitioner statement

RCGP Scotland first began writing this paper in 2017. At that time, the Advanced Nurse Practitioner (ANP) role was the main, rapidly evolving new role within primary care. The paper intended to serve as an analysis of how the roles of generalist ANP and general practitioner complemented and bolstered each other. Whilst providing a very different function within the team. Over the time that this paper has been discussed and refined within our Scottish Council. The landscape of primary care has continued to evolve further. Largely in response to the worsening capacity issues within general practice.

The new Scottish GMS contract for GPs and the National Health and Social Care Workforce Plan (Part Three) describe models of healthcare delivery that are increasingly dependent on the expansion of primary care teams (both within and out-with practices) to deliver care through various new healthcare roles (for example primary care pharmacists and primary care paramedics).

The valuable role of ANPs (and others) acts to complement, but not replace, the role of GPs. Having completed ten years of medical training at an undergraduate and postgraduate level. GPs remain the most appropriate clinician to manage complex, undifferentiated illness, and act as the pragmatic ‘boundary specialists'. Between primary and acute care, keeping patients out of hospital and managing them where possible in the community. This is achieved by virtue of the GP’s ability to tolerate uncertainty and manage risk. Usually in the context of long-term relationships with their patients and families.

Dr Carey Lunan, Chair of RCGP Scotland

Across the UK, we are witnessing similar trends in efforts to expand and enhance the general practice team and where appropriate, to develop advanced roles for these professionals. Of course, there has been diversity in policy and implementation related to new roles, and across all four nations RCGP has fed into this transformation. RCGP Scotland has already worked with the Royal Pharmaceutical Society in Scotland (RPS) in developing a joint policy statement on pharmacists in general practice^iv. The role of Advanced Nurse Practitioners is gaining emphasis and momentum within the Scottish healthcare system.

In February 2016, First Minister, Nicola Sturgeon announced a funding increase of £3 million to train an additional 500 Advanced Nurse Practitioners. An accompanying Scottish Government press release stated that the intention of this funding increase was to, ‘bolster the skills of the profession and equip nurses across Scotland to maximise their leading role in the integrated health care of the future.^v’

The investment in ANPs to support the expansion of care requirements in the community coincides with a period of sustained disinvestment in general practice in Scotland.^vi This disinvestment, coupled with the challenges facing GP recruitment has resulted in general practice in Scotland requiring increased investment and support. This is essential before GPs will have sufficient capacity to provide a worthwhile contribution to training ANPs and the necessary decision support to ensure safe and effective patient care.

RCGP Scotland has publicly raised concern over the suggestion by a Scottish health board that ANPs could be used as a ‘replacement’ for GPs in delivering care to patients during periods of annual leave for GPs as a means by which to reduce Locum costs. Any move towards the replacement of GPs by ANPs is viewed by RCGP Scotland with significant concern for patient safety and is deemed to be resolutely at odds with our Core Values^vii.

The evolution of different nursing roles through practice nurse development, and the historical nurse practitioner role. Are causing some confusion with definitions and inconsistencies in understanding and measuring the current ANP workforce in practice. ANPs were not identified within the Information Services Division (ISD) National Primary Care Workforce Survey 2015.^viii

An Advanced Nurse Practitioner is described by the Chief Nursing Officer’s Department (CNOD) as ‘an experienced and highly educated Registered Nurse who manages the complete clinical care for their patient, not solely any specific condition’^ix. Advanced practice represents, ‘a level of practice, rather than a type or specialty of practice... Advanced and specialist practitioners may be functioning at an extremely high level of practice, but with a different clinical focus.’

ANPs are educated at Masters Level in advanced practice and are assessed as competent in this level of practice. As a clinical leader, they have the freedom and authority to act and accept the responsibility and accountability for those actions. This level of practice is characterised by high level autonomous decision-making, including:

• assessment,
• diagnosis,
• treatment including prescribing, of patients with complex multi-dimensional problems.

Decisions are made using high level, expert knowledge, and skills. This includes the authority to refer, admit and discharge within appropriate clinical areas. Working as part of the multidisciplinary team ANPs can work in or across all clinical settings, dependent on their area of expertise^x.

Producing an agreed definition and the required criteria to be an ANP has been important and helpful, but the current definition of ANPs (as described by the CNOD) is difficult to apply in a clinical context as it covers experienced nurses working in diverse situations in hospital and the community. Defining ANPs by level of practice rather than expertise within a specific clinical setting means that qualifying as an ANP for specialist hospital practice does not prepare an ANP for working in a GP practice or ensure the necessary skills.

ANPs working in general practice and the wider primary care setting must be competent to work in these clinical contexts with different skills to those required in hospital teams. We welcome and support the recognition of this by the nursing profession and the work done to date as part of the remit of the 'Transforming Nursing Roles - Advanced Practice Group.' In developing the core competencies across the four pillars:

• clinical,
• educational,
• leadership,
• research

The additional skills required in defined clinical areas including general practice and community care.
However, the remit for ANPs working in general practice is, by its nature, very wide ranging and we have concern about the extent to which the current competency framework meets the needs of training for this role.

A key attribute of general practitioners is the unique and distinctive broad ranging scope of diagnostic and management skill acquired over at least 10 years of training and crucially the ability to tolerate risk and uncertainty. There is considerable concern whether our ANP colleagues will be similarly equipped to manage and tolerate such risk ensuring there is appropriate control over referral to other services whether it be out patient or acute hospital services. General practitioners and RCGP Scotland must play a substantive and essential role in the training and preparation of ANPs for working in general practice. But there remains considerable concern about the capacity for supporting ongoing training and the guidance and external support available to GPs in this role. An additional potential challenge is ensuring the retention of ANPs within practices that have invested time and effort in their training and an acknowledgement of the longer-term advantages of formalising a social contract.

The Nursing and Midwifery Council do not regulate specifically for advanced practice as an entity and the governance for ANPs lies with the employing health board. It is surprising that a professional group’s own professional body seems reluctant to take responsibility for this governance raising further concern around the robustness of such an arrangement and consistency of approach. However, the RCN is now offering a credentialing opportunity for ANPs who meet their advance level nursing practice standards and a voluntary register which can provide a level of assurance that certain standards have been met. A governance framework has been agreed by the Advanced Practice Group but RCGP Scotland will need more clarity on the governance arrangements around ANPs in general practice and the robustness of their appraisal and revalidation process in assuring satisfactory evidence of maintaining competence. In relation to indemnity arrangements for ANPs, MDDUS have clarified that indemnity cover for clinical care, training, and supervision for ANPs is covered through the practice’s existing defence arrangements. We acknowledge the work done in Dumfries and Galloway through their advanced practice training programme in developing guidance for GPs but need to see this disseminated and adopted more widely.

There has been significant concern about some of the apparent health board actions suggesting ANPs will work in place of GPs. As yet, the evidence surrounding the effectiveness of ANPs in terms of hard clinical outcomes is limited. There is some limited, positive data on patient acceptability and satisfaction however here is a need for much more in-depth ANP metrics to fully evaluate their overall effectiveness in general practice. It can be reasonably assumed that the time required to train GPs in covering the extensive content of the GP curriculum, meeting the required standards set by our College, and in being approved by the GMC, across all the professional competencies, results in a different level of performance to that achieved through the training of ANPs.

Feedback from our RCGP Patients in Partnership Group (P3) has raised concerns from the patient perspective about the importance of informed patient choice and the decision to make informed choice about which health care professional they will see. They also highlight the need to be able to provide feedback on their experience of consulting ANPs and the expectation that ANPs will hold similar core values.

The current challenges facing the nursing workforce are well known with around a quarter of the current workforce in their 50s and a measurable proportion approaching retirement. In September 2017, ISD reported Scotland holding a 5.2% vacancy rate of nursing and midwifery posts, equivalent to 3,200 posts^xi. We therefore anticipate significant difficulties in achieving an ANP workforce which can make a meaningful contribution to workload in general practice.

RCGP Scotland unreservedly supports the valuable role Advanced Nurse Practitioners can bring to patient care in general practice as safe and effective clinicians who form an integral part of the wider enhanced team both in hours and out of hours. This is congruent with a recurring theme of cohesion and teamworking. However, we recommend caution to ensure that this important primary care professional will complement and bolster the role of the GP, but not substitute for that role. We must remain mindful of the potential risk of fragmentation of care, the risk to continuity with some proposed models of care and the pitfalls of a ‘sticking plaster’ approach to GP recruitment and retention difficulties. It is important that the contribution of ANPs is not overestimated as a tangible solution to the sustainability of general practice. The minimum training requirement of 10 years for general practitioners mean that GPs are optimally trained to manage the complexity and risk of general practice. With a sufficient GP workforce, capacity and resource in general practice, GPs can contribute to the training of ANPs in practice and provide the level of decision support required and expected for safe and effective patient care.

ⁱ Royal College of General Practitioners Scotland. A blueprint for Scottish general practice: A strategy for a safe, secure and strong general practice in Scotland. Edinburgh, 2015 http://bit.ly/2zPACU8 [accessed 30 October 2017]

ⁱⁱ The Scottish Government. National Health and Social Care Workforce Plan – Part 1 a framework for improving workforce planning across NHS Scotland. 2017 [accessed 30 October 2017]

ⁱⁱⁱ The Advanced Practice Group. Transforming Nursing Roles Developing Advanced Practice in NHS Scotland. 2016 [accessed 30 October 2017]

^iv Royal Pharmaceutical Society Scotland, Royal College of General Practitioners Scotland. Joint Policy Statement on General Practice Based Pharmacists. http://bit.ly/2ziwWOj [accessed 30 October 2017]

^v The Scottish Government. A modern health workforce. 2016 [accessed 30 October 2017]

^vi RCGP Scotland, Response to the Scottish Parliament’s Health and Sport Committee consultation on the Draft Budget 2018-19. 2017 [accessed October 2017]

^vii David Webster, Royal College of General Practitioners Scotland. Core Values: Benchmarks, scales and yardsticks. 2016  [accessed 30 October 2017]

^viii Information Services Division (ISD) National Primary Care Workforce Survey. 2015 [accessed 30 September 2017]

^ix Chief Nursing Officer Department. Transforming Nursing, Midwifery and Health Professions’ (NMaHP) Roles: pushing the boundaries to meet health and social care needs in Scotland [Accessed 30 October 2017]

^x The Advanced Practice Group. 2016 Transforming Nursing Roles Developing Advanced Practice in NHS Scotland. [accessed 30 October 2017]

^xi Information Services Division (ISD) NHS Scotland Workforce Information, 2017 [accessed 31 January 2018]

^xii Royal College of General Practitioners, General Practice Foundation and Royal College of Nursing ‘General Practice Nurse Competencies’ 2015  [accessed 27 August 2018

^xiii Royal College of General Practitioners, ‘An RCGP position statement on the wider clinical team in general practice’ 2018, [accessed 27 August 2018]