Cliff Kilgore is a Consultant Practitioner Older People, Dorset Healthcare NHS Community Trust and Visiting Fellow to Bournemouth University, Chair of BGS Wessex. He tweets @kilgore_cliff
We should never lose sight that most older people live well in older age. However, we are also very familiar with the challenge of a population that is ageing with all the risks associated with co-morbidities and complex health and social care issues. The realisation that the population needs highly skilled professionals to meet their needs is something we are all aware of and yet both the Royal College of Physicians and the BGS have recently highlighted the significant shortfall for training of medical geriatricians who are seen as the bedrock of older people’s healthcare. We also see healthcare services continually evolving, with the growth of hospital at home, ambulatory clinics, and many other new initiatives focusing on individualised care and making every attempt to not hospitalise older people unnecessarily with all the risks deconditioning brings. However, these innovations are also contributing to the workforce burden as managing the healthcare of older people in a different setting can be complex and requires a level of skill normally associated with medical geriatricians or specialist physicians.
Some of you will know me well and know that I have championed the role of advanced clinical practitioners for many years. Whilst advanced clinical practice has been a part of healthcare provision for several years, there has been a growing necessity and urgency to understand the contribution Advanced Clinical Practitioners (ACP) make to a health care service under huge pressure. ACPs has been increasingly recognised to provide clinical leadership in many areas of healthcare, with good examples highlighted by Health Education England, particularly during the Covid pandemic. HEE in England and HES in Scotland have led work on understanding how clinical staff can be developed to match the challenge of patients with ever-increasing complex needs. However Advanced Clinical Practice across the UK is not regulated, and the roles individuals undertake vary.. Although in my experience this does not seem to worry patients, it can be concerning to other healthcare professionals who may lack the understanding of the assurance that is now in place for the role of advanced clinical practitioner.
During this week when advanced clinical practice is being highlighted and celebrated, it is worth reminding ourselves how this is defined by Health Education. ‘The Multi-professional Framework for Advanced Clinical Practice’ tells us:
“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.”
With this in mind, can we see the role and the skills that advanced clinical practitioners bring as part of the solution for ensuring we have expert clinical leadership for older people’s healthcare? Well, there is increasing evidence that ACPs can indeed provide the complex clinical interventions for older people in many clinical settings. My own recent joint research project with Bournemouth University is indicative of this. Our study highlighted how advanced clinical practitioners were able to deal with complexity and unpredictability when faced with making medical decisions for older people. These included assessments, diagnosis and treatment of older people in many different settings. There was also a demonstration that advanced clinical practitioners had started to recognise deconditioning caused by the pandemic lockdown even in the early stages of the pandemic and were making service changes to meet this new need. To me, this highlights the vital role of being a clinical leader. Leadership from any practitioner delivering healthcare must include a high level of quality improvement thinking, something we talk a lot about in the BGS!
I am not saying we need to stop training geriatricians, but I am saying we could have the very answer to geriatrician shortages in front of us in the form of ACPs. I would like to challenge us all to consider what is a geriatrician anyway? The Oxford Dictionary says a geriatrician is ‘an expert in the branch of medicine or social science dealing with the health and care of old people’. If we agree with this definition, then advanced clinical practitioners can certainly be one of the solutions to workforce shortages in older people’s healthcare!