To boldly go….into advanced practice

Are we really ready to think and act differently; to face the discomfort of breaking out of our silos?

Clinical Scientists are ideally equipped to lead healthcare transformation but we need courage to rethink elements of our service provision. Forget about the organisational barriers. If we could start from scratch, what would ‘good’ look like?

This is a call to action!

An older population has a lifetime of exposure to risk factors often magnified by social inequality. More people have several chronic conditions which interact to produce symptoms and acute events. Our current system of increasingly specialist services tends to see people as discrete diseases or tests rather than approaching care from a holistic perspective.

Patients complain about the number of appointments, the need to repeat their story again and again, the lack of communication between teams, the lack of focus on self-management and prevention of events. Add to this the unnecessary, repeated tests and the environmental impact of wasted resources and it becomes clear that our current model of care is not sustainable.

It is time to reflect on what we do as Clinical Scientists. How can we improve our services to meet the needs of the person in front of us?

There is no doubt that to offer the best healthcare we need more multi-disciplinary teams. We also need some of our scientists to be working at the very top of their licence in an extended scope of practice.

This is not for the faint-hearted. It is uncomfortable. There are risks.

Extending beyond our safe and comfortable scientific practice means moving into a new world where there is uncertainty and ambiguity. Where information is incomplete, complex and complicated and where we are accountable for the clinical care of patients.

This is the world of advanced clinical practice.

Not an imitation medic!

This is not about becoming a poor imitation of a medic. Nor is it solely about reducing cost and waiting times for tests. Cost and waiting times are important elements of healthcare provision but faster and cheaper is of no use if it leads to inaccuracy and worse outcomes.

This is about nurturing the unique strengths and talents of clinical scientists. It is about supporting the right people to design, deliver and evaluate innovative care.

Image: Dr Nolan Stain, Cardiac Clinical Scientist, preparing to insert an implantable cardiac monitor

Confused about what advanced clinical practice is? You’re not alone

  • Is a Clinical Scientist always an advanced practitioner?
  • Do you have to be on a statutory register to be an advanced practitioner?
  • Are advanced practitioners usually employed at consultant grade?
  • Do you need a particular qualification to have an advanced practice role?

I’m not sure whether there are clear answers to these questions at the moment. I hope that this blog will stimulate some discussion in our community. It would be fantastic to hear more from the National School of Healthcare Science (NSHCS) on the matter since much of what is written is primarily for nurses and allied health professionals.

In my view, we seem to be in a transition between the old and the new. As a result, there is significant variation in the interpretation of the term ‘advanced practice’ across the country. Service pressures in the NHS have resulted in pockets of innovative practice where individuals have extended their clinical scope of practice to improve care. These are brave pioneers who have piloted the safety and efficacy of new models of care without the benefit of a framework or structure to guide them.

There is now an increasing recognition that advanced clinical practice roles are vital in service transformation. To unleash the potential of these roles, to ensure safety, and to standardise practice, Health Education England (HEE) has proposed a multi-professional definition of advanced clinical practice:

Advanced clinical practice is delivered by experienced, registered health and care practitioners. It is a level of practice characterised by a high degree of autonomy and complex decision making. This is underpinned by a master’s level award or equivalent that encompasses the four pillars of clinical practice, leadership and management, education and research, with demonstration of core capabilities and area specific clinical competence.

Advanced clinical practice embodies the ability to manage clinical care in partnership with individuals, families and carers. It includes the analysis and synthesis of complex problems across a range of settings, enabling innovative solutions to enhance people’s experience and improve outcomes.

Health Education England

Does this apply to us?

Advanced practice roles are more well established in nursing and the allied health professions but HEE have said in their advanced practice FAQ that healthcare scientists can be recognised as ‘advanced clinical practitioners’, providing they meet the requirements outlined in the framework (see link below).

It is certainly a good idea to have parity across professions and the definition does offer some clarity for practitioners, employers, education providers and the public. It might answer some of our questions. The definition shows that the journey to advanced practice is usually at MSc level and includes 4 pillars

  1. Clinical Practice
  2. Leadership and Management
  3. Education
  4. Research

These elements feature in the Scientist Training Programme (STP). However, it is also evident that significant experience, deep specialist knowledge and broader clinical skills are needed.

Q. Does this mean that the STP alone does not equip a person for the demands of advanced clinical practice? Are additional experience and work-based training required?

The second part of the definition is also important because it defines the ability to manage clinical care across a range of settings. There are many highly specialised Clinical Scientists, expert in their area, who do not manage clinical care.

Q. Does this mean that being a Clinical Scientist with specialised scientific practice is not necessarily the same as being an advanced clinical practitioner.

What do you think?

A doctoral level qualification, which is needed for Consultant Clinical Scientist roles, is not a requirement for becoming an advanced clinical practitioner. Nevertheless, Consultant Clinical Scientists are operating as advanced clinical practitioners in some disciplines.

Perhaps we should view advanced clinical practice roles as existing along a continuum. Some are scientists who are ‘learners’ needing direct supervision as they develop their experience and clinical decision making skills, others are experienced in the role and working with indirect support, and some are operating at consultant level on a par with medical colleagues.

To gain a more detailed understanding of the expectations of an advanced clinical practitioner, I recommend reading the HEE Multi-Professional Framework which lists core capabilities for advanced practice.

One thing is very clear in this framework document; HEE is sending a clear message to employers that only those on a statutory register for their profession should be considered for advanced practice roles (see the flowchart on p.16).

This should serve as real encouragement for anyone in an extended role to join the HCPC register! Take a look at the route 2 information on our website for more information.

Is advanced clinical practice always the right route?

Quality improvement and service transformation do not always require advanced clinical practitioners. We must consider what is best in our community, for the people we serve.

One way to approach this would be to start by gathering details about the typical patient journey – the whole patient journey, not just the part that currently involves clinical scientists! Where are the problems, the delays, the complaints, the incidents, the poor outcomes? Map the journey and consider who is currently involved and where.

NHS improvement has some useful resources on tools that can be used to efficiently map the patient journey.

It is important to view the journey from the patient perspective. What are their concerns and expectations? What do they value most? Patients and the public should be involved at all stages – this is not something to be added on at a later date.

For public engagement to be effective, we need to build trusted relationships. The Kings Fund has good information on this.  “Patients as partners: Building collaborative relationships among professionals, patients, carers and communities” is an accessible report which contains some very practical and easy to use tips.

Once the current service and patient perspective is well understood, we can think about whether we are currently offering value-based healthcare and what ‘good’ would look like from an individual, organisation and population perspective. In doing this we shouldn’t just consider service metrics. Clinical outcomes, patient reported outcome measures (PROMs) and patient reported experience measures (PREMs) are also important. As scientists we understand the need to measure something to improve it!

Armed with this information, we can think about what steps need to be taken to improve those outcome measures; it informs the structure of a new service.

Naturally, we should only use validated outcome measures and select those which match the concerns and expectations of our patient partners. In an ideal world we would standardise outcome measures across the country, as has happened in national audit programmes, to allow us to compare services. These measures would encompass generic and disease specific outcomes.

The International Consortium for Health Outcomes Measurement (ICHOM) has validated several ‘standard sets’ of outcome measures that can be accessed with a free registration. These include atrial fibrillation, coronary artery disease, heart failure, diabetes, limb abnormalities, breast and lung cancer, stroke and many more.

Respiratory Clinical Scientists improving outcomes through advanced practice:

 Joanna Shakespeare (@shakeyjs) has worked with a multi-disciplinary team to transform the acute non-invasive ventilation (NIV) service at University Hospitals Coventry and Warwickshire NHS Trust. 

In the previous patient journey, ward staff assessed acutely unwell patients and initiated NIV. But high vacancy rates and low confidence were impacting on patient care and outcomes. Acutely unwell patients were not always assessed in a timely manner and there were delays in initiating NIV. The overall mortality for patients requiring acute NIV was higher than the national average.

Respiratory Clinical Scientists are experienced in oxygen assessment, blood gas measurement, domiciliary NIV and mask selection/problem solving skills. These are all relevant to an acute NIV service. Joanna and her team wanted to develop a new model to support and complement existing ward staff. They thought that a better service could be delivered using a multi-disciplinary approach. Scientists had to develop skills in clinical assessment which included auscultation, blood test and x-ray interpretation. They had to recognise when and how to escalate a patient to consultant or intensive care. They had to develop confidence in communicating with ward and medical staff about patient care, which included making recommendations for medical management and initiating therapy.

Scientists took clinical assessment modules either as part of their academic training courses (HSST) or independently at a local university. The team also developed a training and competency package split at three levels according to staff requirements. This is being rolled out across the Trust so that any staff that have involvement in NIV can be trained and assessed in a standardised manner.

In the new service model, a Respiratory Clinical Scientist holds the NIV bleep 8am to 8pm Monday to Friday. When called, the scientist assesses the patient, decides whether to start NIV, sets the patient up and manages them prior to moving them to the respiratory ward.

This service is having a significant impact on outcomes. NIV is established sooner and the mortality for patients using acute NIV has fallen significantly to 15%; the national average is 26% (British Thoracic Society audit, 2019). You can read more about the results of the service in this published abstract.

If you’re interested in reading more about advanced practice roles in Respiratory Science check out the article from Joanna and colleagues  in Breathe.

Preparing for a role as an advanced clinical practitioner

HEE have produced a helpful toolkit of resources relevant to advanced practice. This is worth exploring if you are interested in the role. The education section defines the need for formal education and training at a university alongside work-based learning and clinical supervision.

The work-based learning and clinical supervision is really important in overcoming any resistance to change that might be felt from other professional groups. It builds trust between disciplines and provides reassurance about decision-making. The example below highlights how this was important in establishing the role of Consultant Healthcare Scientist in histopathology.

There is also a need to demonstrate ongoing competence and capability through a portfolio (see the practitioner section of the toolkit). The toolkit suggests that this could include evidence of

  • Observed procedures (DOPS)
  • Case-based discussions (CbD) or records of case exams with senior clinicians
  • 360-degree assessments
  • Reflective accounts
  • Evidence of educational sessions and, where appropriate, evaluations
  • Records of audits

Consultant level Advanced Clinical Practice in Laboratory Sciences:

Dr Jo Horne (@hornej13) is a Consultant Healthcare Scientist (HCS) in cellular pathology at University Hospital Southampton.  

Jo has a consultant level qualification in gastrointestinal histopathology. She independently reports specimens, working alongside medical consultants as part of the clinical reporting team. This includes taking full responsibility for specimens and exercising professional judgement when issuing reports and discussing cases with clinical colleagues.

Jo’s route to independently reporting specimens was through a pilot project between the Royal College of Pathologists and the Institute of Biomedical Science (IBMS). Scientists undertook training alongside their existing clinical, scientific, and managerial roles. The training spanned several years and included a competency exam after 1 year and an exam at an equivalent level to FRCPath part II after a further two years. Successful candidates then entered the final stage of training, similar to that undertaken by medical pathologists, which developed independent practice at consultant level. This stage lasted around a year and preceded the Certificate of Completion of Training, which then provided a route into formal posts. The success of the pilot scheme resulted in a formal programme with routes in gastrointestinal pathology, gynaecological pathology and dermatopathology.

There is a national workforce shortage of histopathologists and Jo actively promotes, supports and helps to develop dissection and reporting qualifications for scientists, working with colleagues from relevant national stakeholder organisations. Participation in national External Quality Assurance and CPD schemes is also an important part of the role.

Jo has published an article which explores whether Healthcare Scientists might avert a histopathology crisis by easing the burden on labs.

Sustainability is important

One of the differences between quality improvement and service transformation is that the latter is meant to be irreversible. Of course there is a need to test and refine but we should plan carefully for the long-term. A service cannot operate effectively if it is entirely dependent on a single trusted individual.

When redesigning the service model we should try to see it through the eyes of other professionals who might support the service in the future.

The role of advanced clinical practitioner should be seen as a career option for other scientists in the department. Consider what would motivate individuals to participate in the new model of care. Think about roles just below and above ‘advanced clinical practitioner’. What are the options for work-based learning and formal education? Involve ‘learners’ in clinical audit, service evaluation and research. Build evaluations of clinical effectiveness and scientific leadership into appraisals so that these skills are recognised and valued by the team.

The example below highlights how a multi-disciplinary team at Guys and St Thomas’ Hospitals transformed the care of people with heart valve disease. This new service model has been sustained for 10 years.

Cardiac Clinical Scientists and sustainability in advanced clinical practice:

Cardiac Clinical Scientists in echo have a high level of autonomy in their daily practice and independently report test results. This includes identifying heart valve disease and using quantitative and qualitative assessment to judge the severity of disease. Valve disease is progressive and there are clear European guidelines for follow-up intervals and intervention points. These are based on the severity of disease and whether it is causing symptoms.

Those with valve disease are typically monitored by their GP and a Cardiologist. However, the watchful waiting period is long, and there is evidence that some become lost to follow-up, have tests performed at the wrong times or are referred for intervention too late.

In 2008, Taggu et al.  showed that a sonographer-led clinic increased the proportion of patients who were managed according to best practice guidelines from 41% to 92%. There was no compromise in safety. The service also reduced unnecessary tests and significantly reduced the number of standard outpatient appointments.

A team at Guys and St Thomas’ Hospitals believed that the development of a bespoke multidisciplinary valve disease clinic with greater input from Clinical Scientists would increase adherence to guidelines and improve outcomes. Patients referred to the clinic are stratified so that cardiologists see new patients, those with complex disease or who are close to an intervention threshold.  The scientist monitors patients with stable moderate or severe native disease and decides on patient follow-up or referral to the cardiologist based on agreed thresholds. A nurse monitors patients after surgery who do not require echocardiography and manages a helpline.

Mark Squirrell, Principal Cardiac Physiologist has actively encouraged those in advanced roles to register as Clinical Scientists and to achieve Consultant status. There is a clear philosophy of developing the workforce to meet the needs of a modern healthcare service. Scientists have been supported to develop new skills in clinical assessment through attendance at a bespoke master’s module and through work-based training led by cardiologists. There are regular multidisciplinary meetings to discuss results, outcomes and triage. This planned access to clinical supervision is important in ensuring the quality and safety of the service.

This multi-disciplinary valve disease service has been running effectively for 10 years. Descriptive data from the clinic was recently published by Chambers et al. in the BMJ journal Openheart. There were 4092 visits to the Scientist element of the service (43% of clinic total) and review by a cardiologist was requested in 10%. The service protocol triggers discussion with the cardiologist at a relatively low threshold for safety. The authors, who include Clinical Scientist Dr Brian Campbell (@DrBrianCampbell), have provided links to their protocol and follow-up assessment sheets with the article, in the hope this supports others to develop high quality clinics. 

How can we support each other to deliver better healthcare?

There is clearly a need to improve communication across organisations and regions. We should share our experiences, methods and results. We must also build a published evidence-base which demonstrates the quality and effectiveness of our work in these advanced roles.

In this spirit of collaboration, Hayley Langridge (co-founder of The Clinical Scientist) is working on a presentation with a team of colleagues which explores the steps others have taken in developing a new scientist-led service. This will be shared through our website soon!

We have also started to build case-studies of advanced clinical practice and scientist-led services on our website. Please get in touch if you have something to share.

OK, that’s enough from me. it’s time to share your thoughts and experiences. I’ve deliberately used questions in this blog and would very much like it if you could tell me what you think. Use the ‘comments’ on this page to link your thoughts to the blog.

Be brave, and have the courage to get uncomfortable – it’s the best way to learn!

Emma (@TheClinSci)

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