Non-medical practitioner roles in the UK: who, where, and what factors influence their development?

Operational definition of a non-medical practitioner

For the purpose of this study, NMPs were considered registered health professionals working in an extended, advanced or new role including, but not limited to, advanced clinical practitioners, surgical care practitioners, surgical first assistants and physician associate or physician assistants in anaesthesia who were registered on a managed voluntary register with the Royal College of Physicians (RCP) or Royal College of Anaesthetists (RCoA).

Exclusion criteria

Participants

All (n=156) acute NHS healthcare providers and private/independent providers (n=90) in England and NMPs in the UK. It was decided to include all NMPs in the UK, as healthcare workforces frequently relocate employment between England, Scotland, Wales and Northern Ireland—even though the numbers of NMP roles will be influenced by the devolved healthcare policies for England, Wales, Scotland and Northern Ireland, which is noted as a limitation of the findings.

Ethical considerations

Ethical approval was obtained from Coventry University (P38400). The study was registered with University Hospitals Coventry and Warwickshire Research and Development Department. Health Research Authority and Integrated Research Approval System were not required. All respondents were provided information on consent to participate and the right to withdraw from the study. Data were anonymised before analysis.

Data collection

This descriptive, exploratory study used two separate online questionnaires; one was completed by healthcare organisations in England and another by NMPs across the UK. No previous study had investigated NMPs using this approach. Questions were derived from reviewing current UK literature, educational curriculum frameworks (RCoA, 2008; RCP, 2012; RCSEng, 2014), expert NMPs and researchers. Both questionnaires were similar but the NMP questionnaire included information about their clinical career. Additionally, free text questions were included to allow respondents the opportunity to explain responses and further explore perceptions of the NMP role. Although two separate questionnaires were purposively used, similar questions gained valuable insight from organisations and practitioners allowing data to be triangulated, adding reliability to the data collected. Both questionnaires were tested for reliability, content and validity, using respondents that matched both study groups; minor changes to wording were made following testing. Questionnaires were distributed and administered using the Bristol Online Survey (BOS) tool, an online survey tool providing a variety of question types and complex data flows, which can be built using filter questions. All (n=156) acute NHS healthcare organisations in England were purposively contacted via the chief nursing officer/director of nursing and chief executive for private/independent providers (n=90), using NHSmail.net with a link to the BOS survey webpage attached to the email for completion by the respondent. Data were collected from 6 June to 31 August 2016; two reminder emails were sent.

NMPs were contacted using snowballing techniques. The questionnaire was distributed via professional organisations associated with NMP roles in England, Scotland, Wales and Northern Ireland: Association of Perioperative Practice, Association of Physician Assistant Anaesthesia, Association of Cardiothoracic Surgical Assistants, Royal College of Surgeons (Edinburgh), one healthcare conference (August 2016), higher education institutions that provided NMP courses, Twitter, physician associate and physician assistant in anaesthesia managed voluntary registers, and health professionals and personal contacts advertised/shared the study's BOS survey link on their websites, social media or emails. NMP data were collected from 6 June to 30 September 2016 with no reminders. Data collection for NMPs was extended to allow for summer holidays and university enrolment. Only the Faculty of Physician Associates declined to advertise this survey perceiving the physician associate role to be more medically aligned.

Data analysis

Quantitative data were analysed using SPSS version 24; non-parametric tests were not used due to the small number of responses under individual NMP titles. Data are therefore presented as numbers and percentages. Qualitative data derived from open questions were analysed using content and thematic analysis.

NMP roles and regional distribution of these roles

From the healthcare organisations in England 29/246 questionnaires were returned, 28/156 (18%) from acute and 1/90 (1%) from private/independent organisations. After data cleaning 23 useable questionnaires remained with an overall adjusted response rate of 9%. Low response rates limit this study's results but the results are considered useful given this was novel and exploratory work. The Yorkshire and Humberside region was classified as the North East of England, while London and East Anglia were classified as the South East of England. From the 23 responding organisations in England, only the North East of England was not represented. Table 1 illustrates the location in England of the responding organisations. Small organisations with <500 beds represented 48% (n=11/23), being evenly distributed between North, Midlands and South of England, while 13% (n=3/23) represented large hospitals >1000 beds. Of the organisation who responded 96% (n=22/23) were NHS trusts or foundation trusts and 13% (n=3/23) were teaching hospitals. All but one responding organisation in England employed NMPs, although this organisation was considering recruitment of an NMP role.

A total of 115 NMP responses were obtained; 19 did not fulfil the inclusion criteria therefore 96 useable questionnaires were analysed. Sample size could not be calculated since exact numbers of NMP do not exist within the UK. NMP respondents represented all UK regions (Table 2). NMP respondents were able to provide multiple answers; their responses indicated NMPs work in a variety of healthcare settings (Figure 1). Unsurprisingly, the NHS was the biggest employer (n=93): 47 in NHS foundation trusts, 46 in NHS trusts, but only 11 were employed in teaching hospitals. Three NMPs were employed by NHS trusts/foundation trusts as well as general practice (primary care). NMP respondents reported being employed under a variety of titles (Table 3); the two most common were surgical care practitioners and physician assistant in anaesthesia. Responding NMPs reported 71% (n=68/96) were employed as an NMP within their organisation for less than 11 years (mean of 8 years) (Figure 2).

Influencing factors in the development and recruitment of NMP roles

From an organisational perspective in England, service needs and workforce development were perceived as the two main factors that led to the development of NMP roles and to a lesser extent changes in national policy. Only one organisation reported developing NMP roles to reduce locum medical expenditure. Similarly, NMPs themselves perceived the role to have developed to improve service and workforce development (Table 4). Successful development was reliant on supportive management, good leadership and organisational commitment. Responding organisations in England reported NMP role development was commonly led by nursing, clinical directors or managers. Qualitative responses from individual NMPs across the UK identified factors that facilitated or enabled the introduction of their role (Table 5); the two most common themes emerging were service redesign associated with the lack of doctors and service flexibility.

Differences were noted in the level of experience required by organisations in England when recruiting NMP roles; 39% (n=9/23) required 3-5 years, while 26% (n=6/23) required more than 5 years' healthcare experience (Figure 3). Interestingly, 82% of UK NMPs indicated having more than 5 years' clinical experience before starting their NMP role, yet of these 21% (n=20) had over 20 years' experience (Figure 4). Cross-tabulation indicated those in physician assistant in anaesthesia roles were more likely to have less than 3 years' experience before taking up their role (n=8). When recruiting NMPs, responding organisations in England reported a registered nurse was considered a suitable practitioner for all roles except the physician associate, and an operating department practitioner was considered suitable for all except the advanced clinical practitioner role and more commonly considered for a perioperative specialist practitioner and surgical first assistant role.

Table 6 illustrates the demographics of the responding NMPs across the UK; 69% (n=66/96) female and 31% (n=30/96) male, 67% (n=64/96) had a nursing background. The majority of respondents worked full-time, Monday–Friday, 30% (n=29/96) worked weekends, indicating NMP respondents work a variety of shifts throughout a 7-day week, while only 10% (10/96) were rostered on-call.

NMP respondents within the UK took up their role over a wide timeframe (Figure 5), beginning in 1996, but numbers steadily increased from 2001. The commencement of NMP roles correlated with national policy development in England. NMPs within the UK reported applying for their NMP role for a variety of reasons (Table 7), commonly to develop personally and professionally, extending their scope of practice, which many considered to be career development, while remaining clinical.

Agenda for Change (AfC) grading varied widely both from an organisational and individual NMP perspective. Organisations in England graded the majority of NMPs at band 7 (n=32); physician associates and physician assistant in anaesthesia were most consistent, band 7-8a, while advanced clinical practitioners had the widest grading from band 6 to band 8c (Figure 6). Organisations in England reported NMP roles commence trainee positions at band 6/7 and attain band 7/8a on successful completion of their training programme. Similarly, NMPs within the UK also reported a wide AfC variation being graded band 5-8d; 52% (n=49/96) were employed on band 7, and 31% were band 8a (Table 8).

Factors influencing role development and recruitment

Organisational respondents from England perceived NMP roles were developed predominately in response to service need and workforce developments such as reduction in the number of doctors from the deaneries. These results differ from previous studies (Kneebone et al, 2006; Smith et al, 2006; Farmer et al. 2011; Quick, 2013; White and Round, 2013; Gokani et al, 2016) which suggest NMP roles were driven by national policies such as European Working Time Directives, which significantly reduced medical cover in clinical practice to a 48-hour working week. Notably, no previous study examined the employment of NMPs and policy developments. Further detailed analysis of this study's findings indicated a potential trend between national policy and recruitment of NMP workforce within the UK (Figure 5). NMPs were steadily employed in the UK from 2001 following the publication of the NHS Plan (DH, 2000), the trajectory continued following various policy directives such as the piloting of extended practitioner roles in line with the work of the Modernisation Agency (DH, 2003) and later changes in junior doctors' working hours, effective from August 2009. Findings also indicate a decline in NMP recruitment in 2011 and 2012. As the majority of NMP respondents in the UK were from England, (n=88/96), it is postulated that the publication of the Health and Social Care Act 2012, which radically changed the structure of commissioning and monitoring services, caused uncertainty within organisations, interrupting recruitment—even though major trauma centres were established in 2012 (DH, 2012).

In this study, organisations within England perceived nursing/clinical directors or managers to have led the development of NMP roles; this differs from other studies, which reported doctors leading the introduction of NMP roles (Smith et al, 2006; Miller et al, 2009; RCSEng, 2016). Additionally, NMPs' qualitative responses within the UK perceived the person leading the development should be clinical and motivated with leadership qualities. This concurs with Kneebone et al's (2006) study, which also suggested ‘active’ leadership was required to develop and sustain the role. This finding is considered important to both successfully develop and implement the role, and sustain the longevity of NMP roles.

From a recruitment perspective (Table 6), this study found NMP roles had a higher male representation than expected (31%; n=30/96). Currently men represent approximately 11% of the nursing workforce (Nursing and Midwifery Council, 2019) and 23% of the overall NHS workforce (NHS Employers, 2018). It is reported that nationally 31% of men achieve AfC band 8a-9 (NHS Employers, 2018). This concurs with a large study by Punshon et al (2019) which analysed UK nursing workforce data and demonstrated that more men were represented at higher pay bands, AfC 7-8c. Given 67% of the NMPs in this study were nurses and these roles generally are graded at a higher banding, the finding of males being attracted to NMP roles is consistent. However, no literature has examined gender differences in NMP roles and therefore this requires further investigation.

Additionally, a wide variation in AfC pay banding ranging from 5-8d was reported by NMPs; 51% (n=49/96) were employed at clinical band 7 and 31% (n=30/96) at band 8a. Although organisational results in England differed, more trainee positions were reported at bands 6/7 achieving 7/8a after successfully completing qualifications. These results are congruent with White and Round (2013), who recommended physician associate roles initially being band 6, progressing to band 7 after 12 months. This tiered approach provides NMPs time to develop skills, competence and confidence to work at an extended/advanced level. Additionally, NMP banding variations may also be associated with organisational financial constraints or recruitment to positions before the national frameworks were published. However, this banding variation highlights a discrepancy between clinical practice and NMP regional frameworks, which recommend a higher tiered banding; band 7-8 (NHS Wales, 2010; Health Education East Midlands, 2014; HEE, 2015; NIPEC, 2016; HEE, 2017b, NES, 2018). Furthermore, nearly a quarter of this study's NMPs in the UK perceived their job descriptions and AfC pay banding were not aligned, suggesting NMPs' roles had evolved beyond their original scope and lacked effective job planning reviews. Moreover, variation in pay-grading within this study may be related to factors such as the variety of different roles, titles, level of supervision and whether the role is funded by the organisation or externally and whether it is considered an extended, advanced or new role.

Nonetheless, the importance of AfC banding cannot be underestimated, as inequality in pay can potentially lead to retention difficulties, a point raised within the qualitative comments. This result concurs with Miller et al (2009) who reported practitioners being ‘poached’ by other organisations after training. Retention is a legitimate concern for organisations, since it takes approximately 3 years to educate NMPs at a significant financial cost. Therefore, organisations should carefully consider banding at the outset, follow published frameworks, and regularly review the role against the NMP's skills and scope of practice, particularly as the service develops.

This study found NMPs in the UK had many years' clinical experience, 21% (n=20/96) had over 20 years and 80% had over 6 years (Figure 4). Furthermore, these results differ from Punshon et al's (2019) large study investigating nursing within the UK, which found nurses achieve band 6 after 3-4 years, band 7 after between 6 and 10 years and band 8a after approximately 7-12 years, and varied depending on gender. NMP qualitative responses (Table 7) indicated experienced practitioners undertake these roles to progress their career clinically, rather than choosing a managerial route. The recruitment of experienced practitioners is consistent with the introduction of new roles such as emergency nurse practitioners (Fotheringham et al, 2011) but is a new result for NMP roles, thus adding to the literature in this field. It is purported that practitioners may take up these NMP roles, having already attained a higher band; however, pre-recruitment AfC banding was not investigated in this study, and is worthy of further investigation.

Results presented in this study demonstrate 67% (n=65/96) of registered nurses undertook NMP roles in the UK. Previous studies raised concerns that NMP roles would further deplete the nursing workforce of highly skilled staff (Gokani et al. 2016; RCSEng, 2016). This is a valid concern, given the retention and recruitment difficulties currently facing the NHS (Buchan et al, 2019), with 10.5% leaving the profession (NHS Digital, 2018), and a significant reduction in nursing students exacerbated by changes to nurse funding (Wilson, 2018). However, this study's NMP respondents from across the UK welcomed the opportunity to undertake the NMP role; some wanted extra responsibility and autonomy, while further extending their clinical knowledge and skills, concurring with Smith et al (2006) and Quick (2013). Therefore recruiting nurses to NMP roles can provide an opportunity to retain nurses in clinical practice, albeit in a different role, using existing skills and developing new skills to benefit patients, while providing a link between nursing and medical staff. This is a view supported by Bev Harden, Allied Health Professional Lead for Health Education England, who suggested advanced clinical practitioner roles can provide a career pathway and assist with retention (Mitchell, 2018). Previously, health professionals' career development was primarily limited to management, education or research (Mitchell, 2018; Snaith et al, 2018).