Core Capabilities Framework for AdvancedClinical Practice (Nurses) Working in GeneralPractice / Primary Care in England

AcknowledgementsThis framework was commissioned by Paul Vaughan, Head of Perceptions andGeneral Practice Nursing, NHS England/NHS Improvement who leads the GPN TenPoint Plan and Beverley Harden, Associate Director of Education & Quality, HealthEducation England.Development of the framework was guided by a project steering group chaired byJulia Taylor, ACP/GP Trainer, GP Training Programme Director, Clinical Lead forGeneral Practice, Advanced Practice Strategy Group (Derbyshire). The leadcommissioner was Karen Storey, Primary Care Nursing Lead (NHS England/NHSImprovement) with project management provided by Andrew Lovegrove, SeniorConsultant and Colin Wright, Frameworks Development Manager (Skills for Health).We are extremely grateful to members of the project steering group for providingtheir guidance, expertise and support. Representation on the steering groupincluded patients, the public and the following organisations:Advanced Practice Strategy Group, DerbyshireAssociation of Advanced Practice Educators (AAPE UK)Avon Local Medical CommitteeHealth Education EnglandLondonwide Local Medical Committees (LMCs)NHS EnglandPublic Health EnglandRoyal College of General PractitionersRoyal College of Nursing ANP ForumSkills for HealthThe Queen's Nursing InstituteWessex Local Medical Committees LtdIn addition, we are grateful to colleagues at many other organisations who providedcomments and feedback on drafts of the framework, in particular:Care Quality Commission (CQC)Nursing & Midwifery Council (NMC)Finally, we wish to thank the 244 respondents to the online consultation survey.Further detail of how the framework was developed is presented in Appendix 3. Health Education England, NHS England and Skills for Health, 2020Copies of this framework may be made for non-commercial purposes to aid workforce development. Any othercopying requires the permission of the publishers.Page 2

Equality and Health Inequalities StatementPromoting equality and addressing health inequalities are at the heart of our values.Throughout the development of the policies and processes cited in this document,we have: Given due regard to the need to eliminate discrimination, harassment andvictimisation, to advance equality of opportunity, and to foster good relationsbetween people who share a relevant protected characteristic (as cited underthe Equality Act 2010) and those who do not share it; and Given regard to the need to reduce inequalities between patients in access to,and outcomes from healthcare services and to ensure services are providedin an integrated way where this might reduce health inequalities.Page 3

ContentsForeword . 5Statements of support . 6Introduction and background . 8Scope of the framework . 10Structure of the framework . 11Synergy with the HEE Multi-Professional Framework for Advanced Clinical Practice(ACP) . 12Who is this framework for? . 13Underpinning knowledge . 16Professional values and behaviours . 16Domain A. Person-centred collaborative working. 17Capability 1. Communication and consultation skills . 18Capability 2. Practising holistically to personalise care and promote public andperson health . 19Capability 3. Working with colleagues and in teams . 21Capability 4. Maintaining an ethical approach and fitness to practice . 22Domain B. Assessment, investigations and diagnosis . 23Capability 5. Information gathering and interpretation . 24Capability 6. Clinical examination and procedural skills . 25Capability 7. Making a diagnosis. 26Domain C. Condition management, treatment and prevention . 27Capability 8. Clinical management . 28Capability 9. Managing medical and clinical complexity . 29Capability 10. Independent prescribing and pharmacotherapy . 30Domain D. Leadership and management, education and research . 31Capability 11. Leadership, management and organisation . 32Capability 12. Education and development . 33Capability 13. Research and evidence based practice . 34Appendix 1. Core clinical skills, core indicative knowledge, key clinical presentations,investigations and referrals . 35Appendix 2. Glossary . 64Appendix 3. How the framework was developed . 65Appendix 4. Bibliography. 66Appendix 5. Routes to becoming an ACP (Primary Care Nurse) . 69Appendix 6. Portfolio and Assessment Materials . 70Page 4

ForewordGeneral practice has always been at the heart of the NHS. General practice andprimary care continue to evolve to meet the increasing and more complex demandsof their communities. Scientific advances mean more screening and treatmentoptions exist and more is understood around the importance of preventing illness,protecting health and promoting wellbeing across the life course. This has neverbeen more important given the stark health inequalities which exist across ourcountry.Primary care has a strong track record of innovation and development; this isparticularly so within the context of workforce development. New roles have evolvedand continue to develop, and nurses have in many ways led the way. New ways ofworking together and the development of general practice and primary care multiprofessional teams will ensure a workforce that is fit for the future.Nurses with advanced clinical practice knowledge and skills will be able to both leadand work within and across multi-professional teams to provide excellent preventionand care for people accessing their services.Fundamentally this framework sets a standard and offers the opportunity forpractitioners to develop and evidence their knowledge and skills, enabling thehighest standards of practice as well as providing a structure for career and roledevelopment within primary care.Our gratitude to all those who led on and developed this framework.Ruth MayProfessor Mark RadfordChief Nursing Officer, NHS EnglandChief Nurse, Health Education EnglandProfessor Jamie WaterallDeputy Chief Nursing Officer, NHSEngland & NHS ImprovementDeputy Chief Nurse, Public HealthEnglandPage 5

Statements of supportThe Royal College of General Practitioners is proud to have supported thedevelopment of this new framework. GP nurses are a vital part of the generalpractice team, providing excellent care and support to patients every day. Thisframework for Advanced Clinical Practice provides scope for GP nurses to take oneven more challenging duties and responsibilities, making an even greatercontribution to patient care. Advanced Clinical Practice is a highly responsible andrespected part of the nursing profession, and we are thrilled that nurses in generalpractice will now be able to secure recognition of their expertise.Professor Helen Stokes-LampardChair, Royal College of General PractitionersThe Association of Advanced Practice Educators AAPE UK has been delighted to bepart of this important work to promote high standards for advanced nursing practicewithin all General Practices in England. Many of the students accessing advancedclinical practice education across our 50 plus member universities have and willcome from this healthcare setting, developing the level of their practice in ways thatoptimise patient consultations and push forward service innovation. This frameworkprovides important clarity for all involved in educating future advanced practitionerson the underpinning knowledge and skills that should be developed and assessed toensure safe and effective care for general practice patients.Katrina Maclaine, Associate Professor (Advanced Practice)Chair, Association of Advanced Practice Educators (AAPE UK)We face many challenges in general practice and although there has been a focuson the GP workforce, we need to be aware of the major challenge with an ageingnursing workforce with many due to retire in the next 3-5 years. The NHS istransforming to a system looking at outcomes rather than activity, building a model inthe community that means less reliance on hospital-based care and removing thehistorical divide between community services and primary care with the creation ofPrimary Care Networks. All of this not only requires an expansion of the nursingworkforce but also needs a rapid development of skills and range of services offered.This will mean the career opportunities for nurses will increase significantlysupported by the introduction of the new primary care fellowships for GPs andnurses.Dr Nigel Watson MBE MBBS FRCGPChief Executive Wessex Local Medical Committees LtdPage 6

This framework is a welcome development which appreciates the role and impactthat primary care nurses have on people’s care – as well as providing a structure tohelp them reach their full potential.We know that practices and patients benefit from multidisciplinary working thatenables professionals with different skills to provide appropriate, timely and effectivecare based around the needs of the individual. This is something we see in good andoutstanding practices across England.As general practice looks to tackle the challenges of providing high-quality care nowand in the future, the clinician working at the level of Advanced Clinical Practice willplay a vital role in not only supporting people today, but also in the way primary careevolves in the face of growing need and workforce pressures.Dr Rosie Benneyworth, Chief Inspector of Primary Medical Services andIntegrated CareCare Quality CommissionGeneral Practice Nurses are vital members of the Primary Care Team. Over mycareer I have seen considerable changes to how my nursing colleagues work, theirprofessional development has led to increasing career development opportunitiesincluding advanced clinical practice. This framework offers clarity and is aspirational.I feel that it is very powerful that this framework was created by a wide range ofstakeholders and is endorsed by the Chief Nursing Officer for England and theDirectors of Nursing of Health Education England and Public Health England.Prof Simon Gregory DL, Deputy Medical Director, Primary and Integrated CareHealth Education EnglandPatients and members of public will welcome this description of ‘Advanced ClinicalPractice’ for nurses in the GP surgery and primary care. They really value youradvanced skills in treating them as an advanced clinical nurse - not just as a seriesof illnesses or conditions - but as a person with needs that you can support and treat.That is what this framework identifies and encourages. We all wish you well in thisprocess.Peter Harris, Patient and public representativePage 7

Introduction and backgroundOver a number of years, the role of the nurse has evolved within primary, communityand secondary care. Nurses have in many ways been the pioneers of enhanced andadvanced roles within many settings including general practice/primary care.The NHS needs a workforce that is fit for the future and nurses with advancedclinical practice knowledge and skills will be able to both lead and work within andacross teams to provide excellent care for people.This framework is for nurses working in general practice/primary care at the level ofAdvanced Clinical Practice (ACP) and throughout the framework they will be referredto as ACP (Primary Care Nurse).Personalised care is one of the five major practical changes to the NHS that will takeplace over the next five years, as set out in the recently published NHS Long termPlan. Personalised care means people have choice and control over the way theircare is planned and delivered. In accordance with this change, the word ‘patient’ hasnot been used throughout the framework and has been replaced with person/peopleas appropriate. The ACP (Primary Care Nurse) can create the opportunity for peopleto collaborate and be involved in their own health and care, if that is what isimportant to them at that moment.Primary care and general practice are ever evolving to meet the increasing and morecomplex needs of local communities/populations. This will require new ways ofworking and the development of multi-professional general practice and primary careteams.ACP (Primary Care Nurse) roles, within general practice/primary care have so fardeveloped without a set standard and this has led to varying levels of attainment,resulting in much disparity. This has created confusion for employers, fellowhealthcare staff and people because of variation in titles, qualifications andcompetency.As such it is recognised that many existing ACP (Primary Care Nurses) will haveareas for development and may need to ‘top up’ their academic knowledge and ortheir capabilities in order to evidence the core requirements in this framework.In an often-challenging clinical environment where people are cared for across thelife span, often with multiple, complex problems, it is imperative to ensure safe andeffective practice and ACP (Primary Care Nurse) capability.This framework has identified a core set of capabilities required both for nurses whowork in general practice/primary care settings seeing people with undifferentiatedand undiagnosed conditions and those using the advanced title. Cliniciansemployed at ACP level work autonomously and are not constrained by protocols.This framework identifies the robust underpinning knowledge and capabilitiesrequired by the ACP (Primary Care Nurse) working with an agreed scope of practicewithin the general practice/primary care multi-professional team, and provides theopportunity for them to embrace the Health Education England Multi-ProfessionalFramework for Advanced Clinical Practice in England. ractice/multi-professional-frameworkIt will allow the ACP (Primary Care Nurse) to demonstrate and evidence theiradvanced level knowledge, skills and behaviours to service commissioners,employers, people utilising health care and the public to enable them to have aPage 8

better understanding and confidence in the ACP level of practice. The ACP (PrimaryCare Nurse) is encouraged to showcase their role(s) and embrace the developmentof primary health care teams and new ways of working.To enable that process the framework has included some assessment and portfoliotools to assist both ACP (Primary Care Nurses) and clinical supervisors to build aportfolio of triangulated evidence of capability.For the purposes of this framework we are using the following definition ofcapabilities:Capabilities are the attributes (skills, knowledge and behaviours) whichindividuals bring to the workplace. This includes the ability to be competent andbeyond this, to: manage change be flexible deal with situations which may be complex or unpredictable and, continue to improve performance.Therefore, ‘capability’ can be more than ‘competence’. To be competent is toconsistently perform to defined standards required in the workplace – usuallyfocused on the outputs of work and observable performance. Competence tends todescribe practice in stable environments with familiar problems. Whereas‘capabilities’ describe the ability to be competent, and beyond this, to work effectivelyin situations which may be complex and require flexibility and creativity.In practice, the terms ‘capability’ and ‘competence’ and are both widely used ineducational and workforce development literature and they have often been usedinterchangeably, with little clear distinction between the two. Both capability andcompetence: are about ‘what people can do’ describe knowledge, skills and behaviours can be the outcome of education, training or experience.However, for the purposes of this framework we are using the term ‘Capabilities’ asthis describes the ability to be competent, and beyond this, to work effectively insituations which may require flexibility and creativity.More information on how this framework was developed is set out in Appendix 3.Page 9

Scope of the frameworkThis framework specifies a range of core capabilities expected of the ACP (PrimaryCare Nurse) working within general practice/primary care. This includes the ability totake a history, assess and examine as necessary, synthesise information and useclinical reasoning to diagnose and formulate a shared management/personalisedcare/support plan.The ACP (Primary Care Nurse) must: Work within the scope of their role, agreed and documented by theiremployer. Work within and across multi-professional teams and draw on theexpertise of all members (including health and social care) to support andmeet the person’s needs and best interests to optimise the integration oftheir care. Manage and escalate medical emergencies appropriately. Identify and act appropriately on red flags. Assess, diagnose and collaboratively agree a way forward, includingshared decision making and personalised care and support planning. Manage medical complexity. Complete episodes of care which may include referral for furtherassessment, treatment and care appropriately. Work with people and where appropriate, carers, to access appropriatetreatment, diagnostics, care and support within the context of individuals’preferences, priorities and needs. Provide continuity of care in collaboration with the person, considering allof their physical, mental and psychosocial challenges. Use interactions with each person to facilitate and enable changes inbehaviour that can have a positive impact on the persons health andwellbeing.The core set of capabilities articulated within this document are the essentialfoundations for working in a generalist environment where ambiguity anduncertainty can be high. This core should be evidenced and maintained.It is recognised that in addition to the core in this framework the ACP (Primary CareNurse) may develop more specialist knowledge at advanced level and areas ofspecial interest. These may evolve in order to meet population or practice need, orindeed out of the special interest of the ACP (Primary Care Nurse).It is the responsibility of the employer to ensure that the ACP (Primary Care Nurse)is capable to carry out the role they are employed to fulfil. The employer andemployee should agree and document the scope of practice within the multiprofessional team. This should be regularly reviewed and therefore it is assumedPage 10

that cyclical appraisal and Continuing Professional Development exist within a wellgoverned clinical working environment1.The Academy for Advancing Practice (presently in development) will provide anopportunity for practitioners working as an ACP (Primary Care Nurse) to evidencetheir ability to work at an advanced level. This may be supported by regional andlocal governance structures.Registered nurses working at an advanced level will need to demonstrate capabilityfor doing so. For the ACP (Primary Care Nurse) a portfolio of triangulated evidenceagainst this framework, along with the necessary academic educational attainmentsupports this process.Structure of the frameworkThe framework is presented in four domains:Domain A. Person-centred collaborative workingDomain B. Assessment, investigations and diagnosisDomain C. Condition management, treatment and preventionDomain D. Leadership and management, education and research.Within the domains are a total of 13 capabilities. The capabilities are numbered forease of reference - this does not indicate a prescribed pathway, process orhierarchy.The capabilities set out what the ACP (Primary Care Nurse) working in generalpractice/primary care settings must demonstrate. The capabilities must beunderpinned by the clinical knowledge to promote health and to assess, diagnoseand manage the care of people.Core clinical skills and an indicative list of person presentations is presented inAppendix 1.Assessment and portfolio tools can be found in Appendix 6.1See Appendix 6. Portfolio and Assessment MaterialsPage 11

Synergy with the HEE Multi-Professional Framework forAdvanced Clinical Practice (ACP)This framework builds upon the definitions of advanced clinical practice provided bythe Advanced Clinical Practice (ACP) Framework (2017)2.Advanced clinical practice is delivered by experienced, registered health andcare practitioners. It is a level of practice characterised by a high degree ofautonomy and complex decision making. This is underpinned by a master’slevel award or equivalent that encompasses the four pillars of; clinicalpractice; leadership and management; education and research, withdemonstration of core capabilities and area specific clinical competence.Advanced clinical practice embodies the ability to manage clinical care inpartnership with individuals, families and carers. It includes the analysis andsynthesis of complex problems across a range of settings, enabling innovativesolutions to enhance people’s experience and improve outcomes.The ACP definition has been developed to provide clarity for employers, serviceleads, education providers and healthcare professionals, as well as potential ACPspractising at an advanced level.All health and care professionals working at the level of advanced clinical practiceshould have developed their skills and knowledge to the standard outlined in theAdvanced Clinical Practice Framework (2017); the capabilities are common acrossthis level of practice enabling standardisation. As well as demonstrating that healthand care professionals have developed to a defined level of practice, there is anexpectation that this is sustained through organisational mechanisms such asappraisal, clinical supervision and support for continuing professional development.Pillars of the ACPFrameworkDomains of the Core Capabilities Framework forAdvanced Clinical Practitioners (Nurses) Working inGeneral Practice/Primary CareDomain A. Person-centred collaborative working1. Clinical PracticeDomain B. Assessment, investigations and diagnosisDomain C. Condition management, treatment and prevention2. Leadership andManagement3. EducationDomain D. Leadership and management, education andresearch4. Research2Ref: HEE (2017), Multi-professional framework for advanced clinical practice in England.Page 12

Who is this framework for?Service commissionersThe framework enables commissioners of services to specify minimum standards forACP (Primary Care Nurse) employment. It sets out clear expectations about whatthe ACP (Primary Care Nurse) can do, recognising that the ACP (Primary CareNurse) has the knowledge and skills to be flexible in their approach and workautonomously to provide evidence-based care for people.This framework will facilitate the inclusion of the ACP (Primary Care Nurse) intoworkforce plans such as by; Clinical Commissioning Groups (CCGs), StrategicWorkforce Improvement Groups (SWiG), Sustainability and Transformation Plans(STP), Integrated Care Systems (ICS) and Primary Care Networks (PCNs).Other organisations involved in the care of people will understand the ACP (PrimaryCare Nurse) level of practice and this will facilitate allowing direct referrals,requesting further investigations (such as imaging etc).The capabilities support the development and planning of the workforce to meet localpopulation need and support a common understanding and expectation of the ACP(Primary Care Nurse) operating at this level of practice, to facilitate the developmentand mobility of this workforce. It will allow service commissioners to understand thevalue of the ACP (Primary Care Nurse) in leading/working within and across multiprofessional teams to deliver the best outcomes for people.EmployersThe framework enables employers and managers to demonstrate that the ACP(Primary Care Nurses) they employ/manage meet core capabilities or havedevelopmental plans in place along with clinical supervision to ensure safe andeffective practice which remains up to date and meets the needs of individuals.This underpins and supports the need for continuing professional development ofACP (Primary Care Nurses) and supports workforce planning - for example: It supports the process of quality assurance to ensure the safety andeffectiveness of advanced clinical practice roles. It can be use as part of appraisal processes. It can be used to review and recognise how capabilities are shared acrossteams.Education and training providersHigher Education Institutions can use the framework to inform the design of theircurricula and the delivery of education, training and development programmes,including identifying learning outcomes. It will enable the synergy betweenframeworks to be identified and thus allow the unique skills required in primary careto be addressed and provided for promoting the development of multi professionalteam working.This will ensure that learning and development provision contributes to ACP (PrimaryCare Nurses) and trainees acquiring and demonstrating the full range of knowledgePage 13

to support the capabilities required to make them a safe and effective member of theworkforce.The framework will inform those who design and deliver training and developmentopportunities to focus on the key capabilities that both trainee and existing ACP(Primary Care Nurses) need to achieve and maintain. This in turn, will guide thecontent to be included and the use of appropriate learning and teaching strategies.Use of this national framework also supports organisational and system wideeffectiveness and efficiencies by encouraging the delivery of education and trainingthat is focused on developing core ACP (Primary Care Nurse) capabilities andoptimises opportunities for inter-professional learning. In so doing, it should help toincrease consistency in knowledge and skills development, prevent unnecessaryduplication in education and training delivery and strengthen skill mix andteamworking.Clinical Supervisors (CS)The framework will assist clinical supervisors of ACP (Primary Care Nurses) andtrainees to better understand the level of practice and provide a framework to assessagainst. The assessment tools in Appendix 6 enable the clinical supervisor tocapture how the trainee or ACP (Primary Care Nurse) applies their academicknowledge, experience and skills to day to day practice. These assessments canform part of the ACP (Primary Care Nurse) portfolio of triangulated evidence.The ACP (Primary Care Nurse) / Trainee ACP (Primary Care Nurse)The framework sets out clear expectations for the ACP (Primary Care Nurse) andtrainee ACP (Primary Care Nurse) about the requirements for effective and safeadvanced practice roles. It provides clarity about the higher level of both academicand clinical competence required.It can be used to conduct formal or informal appraisal, alongside a training needsanalysis, comparing current skills and knowledge with required skills and knowledge.It can also be used to support revalidation requirements with the NMC.Existing nurses currently using the “advanced” title may have different starting pointsdue their clinical background, experience, clinical setting and scope of practice. Theymay meet all or some of the capabilities but may need to ‘top up’ their skill set tothose outlined in this framework and to evidence capability and work effectively in ageneral practice/primary care setting.New trainee ACP (Primary Care Nurses) need to be employed in a trainee post, withclinical supervision, that will allow them to see appropriate presentations for them todevelop and evidence the core capabilities in this framework.This framework will assist ACP (Primary Care Nurses) in the development of aportfolio of triangulated evidence. It will allow ACP (Primary Care Nurses) todemonstrate their capability in working at an advanced level.The various routes to becoming an ACP (Primary Care Nurse) are presented inAppendix 5.Page 14

People and the wider publicThe framework can be used by people to understand what they can expect from anACP (Primary Care Nurse) when planning for their own current and future care. Inparticular, the framework outlines the skills an ACP (Primary Care Nurse) mustdemonstrate in supporting people (an

Nursing & Midwifery Council (NMC) Finally, we wish to thank the 244 respondents to the online consultation survey. Further detail of how the framework was developed is presented in Appendix 3 .