Exploring Collaborative Models of Advanced Practice in Community and Primary Care in Wales, UK

Background: In the United Kingdom (UK) the title ‘Advanced practitioner’ is an umbrella term that encompasses previous titles such as nurse practitioner, or clinical specialist from many different disciplines (Ryley & Middleton, 2016). There is international and national recognition of the contribution which advanced practitioners can make to meeting increased primary health care needs (Carter, Owen-Williams & Della, 2015; IOM, 2011; Welsh Government 2015a, 2015b). Within Wales there is strong government support for expanding the role of advanced practice in primary and community care in order to ensure a sustainable and efficient service to meet patient and population needs (Welsh Government, 2015a). Primary care services are changing, demand is rising in view of an ageing population with more complex needs and an increased number of people living with chronic conditions including mental health conditions being cared for at home (The King’s Fund, 2013). Traditional models of general practice are becoming less attractive compounded by challenges in recruiting and retaining General practitioners (GPS) especially in more deprived areas (Watkins 2016). Ensuring a sustainable primary care workforce is viewed by Welsh Government as being more diverse, with increased multidisciplinary working, expansion of new roles including advanced practice and premised on prudent healthcare principles (Welsh Government, 2015a). A fundamental prudent healthcare principle, is that the workforce is organised around the `only do what only you can do principle’ so that all members of the community and primary care workforce work to the maximum of their clinical competency and education. Therefore `No GP should routinely be undertaking any activity which could, just as appropriately be undertaken by an advanced practice nurse, a clinical pharmacist or an advanced practitioner paramedic worker (Welsh Government 2015b, p2). Despite emerging models of advanced practice, few studies have sought to explore the nature and scope of advanced practice in Wales to inform future workforce planning.

Aim of the study: To explore the scope and nature of the advanced practice workforce within community and primary care in one Health Board in Wales.

Methods: A mixed methods study including a questionnaire (n=17), focus groups, individual face to face and telephone interviews was conducted. Samples included advanced practitioners (n=23), advanced practitioner team leads (n=3), GP and advanced paramedic leads (n=5). Data were collected between October 2016-April 2017. Ethical approval was gained. Quantitative data were analysed using descriptive statistics and qualitative data by thematic analysis.

Findings: Four themes were identified from the qualitative data: Recognition and awareness of advanced practice; Leadership, management and formal education; Future provision of services by advanced practitioners and Workforce needs and skill mix. This presentation will focus on findings from the latter three themes. The findings indicated that a supportive management structure enhanced the service. Demands on the service inhibited continuing professional development and advanced practitioners reported that leadership skills were learnt on the job and needed higher priority in their education programme. Working as an advanced practitioner in the community required differing levels of skills in management and leadership to being in hospital. A lack of standardisation as to how advanced practitioners operate in the community with different eligibility criteria for referrals caused confusion. Opportunities for expanding advanced practice services to be more proactive than reactive were identified and will be presented. All of the advanced practitioners in the community and in primary care worked in skill mixed teams often in the former determined by the merging of existing teams rather than based on clinical needs. The data also identified the need for community teams ` to grow their own’ through training Advanced practitioner trainees and upskilling their existing staff. Findings indicated that risk aversive practice by GPs, paramedics and A&E departments resulted in patients being admitted to hospital when they could have been managed at home.

Implications: The need for a systematic, bottom up approach to inform evidenced based decision making regarding redesigning services and re-modelling the workforce was identified. Additionally there needs to be a cultural change to address risk averse practice in order for prudent health care to be effectively implemented and for avoidable hospital admissions to be prevented and early discharge facilitated. Finally in determining future workforce needs in relation to advanced practice there is a need for a whole systems approach to workforce planning as opposed to focusing on just one level of practice.