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Nigel's surgery 66: Advanced Nurse Practitioners (ANPs) in primary care
This issue of Nigel's surgery has been updated to include information about the RCN credentialing programme and the HEE/NHSI multiprofessional document.
Nurses are increasingly extending and expanding their scope of practice beyond initial registration with the Nursing and Midwifery Council (NMC).
They are now commonly working at an advanced practice level in general practice.
Advanced level nurses in general practice
Advanced Nurse Practitioner means a nurse with Level 7 MSc qualifications in clinical assessment. This includes:
- history taking
- physical examination and
- independent prescribing,
so they can safely work in a first contact role to manage patients who present with a range of symptoms not previously assessed by another appropriate Health Care Professional. Nurses working at an advanced level can be employed in roles such as the ANP. They must show capability against the Core Capabilities Framework for Advanced Clinical Practice (Nurses) Working in General Practice / Primary Care in England
In primary care networks and integrated care systems, advanced level nurses may work in a variety of roles. The NMC standards state that registered nurses working at this advanced level must:
- have an active registration with the NMC
- practice within the four pillars
- have a Job Plan that shows advanced nursing practice and equity with peers working at this level
- be educated to Masters level
- be an independent prescriber
- meet NMC revalidation requirements
- demonstrate autonomous evidence
The ANP role
The role has developed partly to address demand and workforce issues. In general practice it is generally understood to mean a nurse who has undertaken extra training in clinical assessment, including history-taking and physical examination, so they can safely manage patients presenting with undifferentiated and undiagnosed conditions.
- prescribe any medicine for any condition within their competence (including some controlled medicines) provided they have completed an Independent Prescribing qualification
- see patients with undiagnosed, undifferentiated medical conditions and make treatment decisions, including ordering necessary investigations
- refer patients to secondary care, although this can vary depending on local arrangements and protocols
- undertake appropriate home visits.
- sign Fit Notes (only medical practitioners can do this by law).
ANPs and the care of pregnant women
The NMC states that only a registered medical practitioner or a practicing midwife can provide assessments and pregnancy related care for a pregnant woman. ANPs in general practice settings may find themselves being asked to provide care for non pregnancy-related conditions that may have an impact on the pregnancy or be called on to provide care in an emergency. Clear referral pathways must be in place for such scenarios.
Should the ANP also be a registered practicing midwife, they will be able to care for pregnant women if they continue to meet the NMC requirements. These include:
- notifying their intention to practice
- maintaining the NMC revalidation requirements for midwifery.
The role develops from competencies common to all registered nurses. In primary care, nurses working at an advanced level operate as generalists. They can care for patients of any age with acute and long-term medical conditions. This depends on the capabilities they have developed. It can also include health promotion.
Nurses working in a first contact role, responsible for managing patients with undiagnosed conditions need to be able to carry out an appropriately focused assessment. Nurses in these roles should always work within the limits of their own knowledge and scope of practice. This includes being aware of when and how to refer on for further assessment. This may be in their own clinical setting or another such as secondary care. There should be clearly defined boundaries agreed with the employer. Each practice will have its own arrangement for the nurse’s scope of practice and how it is organised. The advanced level nurse should have the capability to manage/organise their own case load and ways of working. They should have arrangements for supervision with someone suitably qualified. For example, a medical colleague or ANP.
Qualifications and professional standards
ANPs must be Registered Nurses with the NMC and must also register their prescribing qualification with them. All non-medical prescribers must follow the General Pharmaceutical Council’s guidance.
The ANP qualification itself is not recorded on the NMC register for the individual nurse so, in theory, anyone can call themselves an ANP. Health Education England (HEE) Centre for Advancing Practice has a role in accreditation of advanced practice programmes at higher education institutes. HEE has set out a programme of accreditation (‘kitemarking’) process for advanced practice education programmes. Nurses working in advanced level roles in primary care can apply to HEE for recognition of prior experience and learning, known as the portfolio route.
The professional standards of practice and behaviour contained within the NMC Code apply to the ANP role. In particular, this includes the sections on recognising and working within the limits of competence and the standards regarding keeping clear and accurate records. The ANP should be:
- Included in communication with the local medicines management team. They should have opportunity to review their own prescribing practice. For example, the rate of antibiotic prescribing, and if it is in line with local guidelines.
- Supported by the practice to stay up to date to meet the requirements of NMC re-registration. This includes revalidation. It also includes part of a system of appraisal to identify and address future learning needs
- Supported within the practice. They should have a system for seeking help when necessary from a medical colleague. Ongoing clinical supervision will include reviewing patient consultation records. It will also include audit of the ANP's practice. This is to benchmark against established best practice.
All nurses must have adequate medical indemnity as part of the need to re-register with the NMC. The NHS operate the Clinical Negligence Scheme for General Practice (CNSGP). This is a state indemnity scheme for general practice in England. It covers clinical negligence liabilities in general practice relating to incidents on or after 1 April 2019. All providers of NHS primary medical services are covered under the CNSGP. The scheme extends to all GPs and others working for general practice who carry out activities delivering primary medical services. The scheme does not cover services provided outside of the NHS. For example, Heavy Goods Vehicle (HGV) medical certificates.
When we inspect
We consider how services make sure that staff have the skills, knowledge and experience to deliver effective care, support and treatment. We consider this as part of
- Regulation 5 (Fit and Proper persons)
- Regulation 12 (Safe care and treatment)
- Regulation 17 (Good Governance)
- Regulation 18 (Staffing)
and as part of our Key Lines of Enquiry (KLOEs). In particular:
- E3 Staff skills and knowledge
- E4 How staff, teams and services work together
- WL4 Governance and management
- WL5 Management of risk and performance
Providers employing nurses in this extended role should be able to show:
- the underpinning training the advanced level nurse has carried out
- how they support their continuing professional development
- how they assure themselves of the nurse’s capability to practise at an advanced level. This is on an ongoing basis. It should include a system of structured supervision and review of consultation records.
Training records and proof of qualifications should be made available.
Health Education England’s Multiprofessional framework for advanced clinical practice in England states:
"employers carry responsibility and vicarious liability for practitioners and must be responsible for ensuring that all advanced clinical practice roles, both those that are existing and those of the future, do not compromise safety"
Core Capabilities Framework for Advanced Clinical Practice (Nurses) Working in General Practice / Primary Care in England. This defines core capabilities an advanced level nurse working in primary care should be able to evidence. It includes a selection of portfolio tools to aid this process.
- An RCN guide to advanced nursing practice, advance nurse practitioners and programme accreditation (RCN, 2012)
- Advanced Level Nursing: A Position Statement (Department of Health). This gives specific descriptors for advanced practice across four domains:
- clinical practice
- leadership and collaborative practice
- improving quality
- developing others
- The Code: Professional standards of practice and behaviours for nurses and midwives (NMC, 2015)
- Multi-Professional Framework (Health Education England)
- In practice: Guidance for pharmacist prescribers (General Pharmaceutical Council)
- Last updated:
- 22 February 2021