What’s an extra two years in a 40-year wait for the regulation of advanced practice?

With it’s focus in the NHS 10-year health plan, what needs to be considered during the development of regulation for advanced practice for the UK, and what is there to be learned from the US, asks John Unsworth

‘Fit for the Future: 10-year Health Plan for England has a central role for advanced practitioners and nurses leading neighbourhood teams. The plan commits to regulation and the rollout of accreditation as soon as possible. However, having decided that advanced practice should be regulated and agreeing a set of principles, the Nursing and Midwifery Council (NMC) recently pushed back consultation on draft standards from January 2025 to the first part of 2027.

That in itself was quite some statement, especially as the NMC said that they had ‘heard clearly from both the public and professionals about the important role advanced practitioners play in delivering care for people. They’ve also said a lack of consistency in education and training, qualifications, responsibilities, and governance processes can create a risk to the public, and that additional regulation will help reduce the risk’.

Advanced practice in the United Kingdom started in the early 1980s with Barbara Burke-Masters working as a nurse practitioner amongst people who were homeless in London. Early nurse practitioner programmes were established by the Royal College of Nursing at degree level and were quickly franchised to various parts of the UK.

As the number of advanced practitioners has risen since then, we have seen various changes including the advent of prescribing and masters level preparation. Multi-professional advanced practice is now widespread across primary care and community services with varying levels of preparation for the role.

Related Article: Government to develop ‘advanced practice nurse models’, says NHS 10-year plan

The NMC has outlined the complexities of regulating advanced practice with four country perspectives and other stakeholders to be considered.

Such complexities are nothing when compared to a country like the United States with 54 separate regulators (State Licensing Boards) and multiple professional bodies and associations. Work on developing an APRN (advanced practice registered nurse) consensus model was led by the National Council of State Boards of Nursing (NCSBN) from 2006 until 2008 when the model was agreed and adopted. While variation between states remain, around areas like full practice authority, the model’s adoption was a landmark in the regulation of advanced practitioners in the United States.

The APRN consensus model sets out not only the regulatory framework, but also the system of certification and education. The model offers a mixed economy with professional associations playing a role in certification and credentialing. Such an approach is essential given the complex way in which advanced practice nursing has developed both in the United States, but also within the UK.

What might the NMC learn from the United States experience?

The consensus model was developed and endorsed by more than 48 organisations. Where consensus was not unanimous a 66% majority vote was used to determine the final recommendations. Through a process of extensive dialogue and transparency, the NCSBN working group was able to develop the entire regulatory framework for advanced practice in less time than the NMC propose as a delay.

One of the strengths of the APRN consensus model is that it is inclusive and recognises the need to onboard existing advanced practitioners from a variety of different roles. While the NMC have indicated that they intend to develop a system for this the process and how this will be handled remains opaque.

We know from the recent NHS England Digital Badge issue and the Additional Roles Reimbursement Scheme (ARRS) that there are a number of individuals practising as advanced practice nurses who hold a variety of qualifications.

We have also seen the impact on individuals and services of a poorly implemented policy such as the Digital Badge. Clearly, a robust system to credentialing that is operated by a range of professional bodies is required to ensure that these practitioners are not prevented from continuing their roles when regulation becomes a reality.

My own and my colleagues’ recent work on advanced practice roles in family and community health services shows that the roles are very similar whether an advanced practitioner is working in a general practice or with people who are homeless in a community shelter.

Related Article: Employers urged to adopt new NMC advanced practice principles

This work also details how advanced practice has five key pillars rather than the four suggested in the NHSE model. The pillars include direct clinical care, leading practice, clinical reasoning, health promotion and ethics. This is hardly surprising given that the four-pillar model has never been empirically evaluated, and is loosely based on earlier work around consultant level practice.

More recently we have explored whether other community practitioners have similar profiles to advanced practice nurses.

Our work on district nursing shows that they have a profile similar to a clinical nurse specialist. Clinical nurse specialists are recognised in the United States and by the International Council of Nurses as advanced practitioners, yet the work in the UK has largely ignored this group thus far. Similar findings amongst health visitors have also been identified. This work has a strong empirical basis, rather than being based on perceptions. It is based on how frequently practitioners perform some of the advanced practice functions, such as assessment, differential diagnosis and prescribing and treatment.

It is clear that any system of advanced practice regulation is going to need to ‘mop up’ more than 40-years of ad hoc role development. Listening to one side, and one view, will simply not work, and the only way to achieve such regulation is through consensus building and reliance on others.

The NMC could go further faster, as the NHS health plan requests, if they heeded the lessons from other countries – let’s just hope they are listening.

John Unsworth is a registered nurse and Professor of Community Nursing Workforce and Policy at Northumbria University. He is a former NHS director and district nurse. He is the chair of council of the Queen’s Institute of Community Nursing and a Fellow of the Royal College of Nursing and the American Academy of Nursing.

Related Article: Supporting the development of advanced nursing skills in community nursing

To read more about the research around advanced practice:

Unsworth J, Oldman C, Atkinson J, Comparcini D, Simonetti V, Cicolini G, Mikkonen K and Tomietto M. (2025), Development and validation of the family and community nursing advanced practice scale. Journal of Clinical Nursing. https://doi.org/10.1111/jocn.17665