As usual first things first:

Disclaimer: The views expressed in this blog are those of the author and do not necessarily represent the views of the Nursing and Midwifery Council, employer organizations, or affiliated institutions.

This blog entry has been written in accordance with the NMC Code (2018), which outlines the professional standards expected of all registered nurses and midwives, including requirements to promote professionalism, preserve safety, and practice effectively.

Shall we?

In the complex landscape of modern healthcare, the roles of Advanced Clinical Practitioners (ACPs) and Enhanced Clinical Practitioners (ECPs) have emerged as pivotal in addressing systemic workforce challenges. While both roles represent advanced practice within the NHS, their scope, autonomy, and contribution to surgical specialties differ markedly. This blog entry aims to explore these differences critically, and to present a robust argument for why surgical services would significantly benefit from the integration of ACPs over ECPs.

Understanding the Framework: ACP vs ECP

Both ACPs and ECPs are registered healthcare professionals who have undertaken additional training to extend their clinical practice. However, the level of training, scope of responsibilities, and the extent of autonomy distinguish the two roles.

Advanced Clinical Practitioners (ACPs) operate at a Master’s level and are defined by Health Education England (HEE) as highly experienced clinicians capable of complex decision-making, managing entire episodes of care, and operating across four critical pillars: clinical practice, leadership and management, education, and research (HEE, 2020). ACPs work autonomously, often leading patient care pathways, prescribing medications, interpreting diagnostic tests, and coordinating multidisciplinary care.

In contrast, Enhanced Clinical Practitioners (ECPs) work at a level above traditional band 5/6 roles (I should be glad I am Band 7) but below that of ACPs. They usually undertake specific, protocol-driven clinical duties within their scope of competence, often under the supervision of senior clinicians. Their role is more focused on extending skills within a defined area rather than taking full clinical responsibility (Skills for Health, 2024).

However, there is growing variation in the ECP role, with some practitioners completing additional qualifications such as the Non-Medical Prescribing (NMP) course, physical examination modules, and clinical reasoning training. These qualifications significantly enhance the capability of ECPs, allowing them to function with greater independence and contribute to more complex aspects of patient care. An ECP with NMP and advanced clinical assessment competencies may begin to resemble the ACP role in practice. Yet, it is essential to note that while these qualifications narrow the gap, they do not necessarily confer the full breadth and formal recognition associated with ACP status.

The ACP role is framed by a comprehensive, Master’s-level educational programme explicitly aligned to the four pillars of advanced practice and assessed accordingly. Without meeting the full national framework for ACP recognition—including sustained practice, academic portfolio, and clinical supervision—it would be inaccurate to equate an enhanced ECP to an ACP. Nonetheless, these developments do suggest the emergence of a potential ‘hybrid’ workforce in some Trusts, blurring traditional boundaries.

Current Guidelines and Transition Pathways for ECPs

Enhanced Clinical Practitioners operating at or near ACP levels raise important considerations for workforce governance and progression frameworks. According to Skills for Health (2024), the ECP Apprenticeship is designed as both a destination and a stepping-stone role. ECPs who pursue NMP and postgraduate modules in clinical reasoning or physical assessment can significantly strengthen their clinical contribution.

However, to transition formally into an ACP role, practitioners must demonstrate achievement across all four pillars of advanced practice. This includes:

• Completion of a full Master’s programme in Advanced Clinical Practice.
• Supervised advanced clinical practice over time.
• A robust portfolio of evidence aligned to the Multi-professional Framework for Advanced Clinical Practice in England.

Health Education England (HEE) encourages employers to support ECPs working at an advanced level by providing structured progression routes and access to formal ACP training. Trusts are increasingly expected to differentiate clearly between those operating under ECP status versus those who meet full ACP recognition to ensure governance, accountability, and patient safety.

Recommendations for ECPs Aspiring to ACP Roles

1. Undertake a GAP Analysis: Identify strengths and developmental needs across the four ACP pillars to inform your learning plan.
2. Engage in Mentorship: Seek guidance from existing ACPs or consultant-level staff to align your practice with advanced competencies.
3. Build a Portfolio: Collect and reflect on evidence of leadership, clinical complexity, research engagement, and education contributions.
4. Enrol in ACP Programmes: Access a university-validated MSc in Advanced Clinical Practice, supported by employer sponsorship or apprenticeship pathways.

The Surgical Setting: A Demanding Environment

Surgical specialties are unique in their intensity, demand for rapid clinical decision-making, and the need for seamless continuity of care. Patients in surgical pathways often require acute assessments, pre-operative optimization, intraoperative support, and complex post-operative management. As such, surgical environments benefit from clinicians who can operate with high levels of autonomy, advanced knowledge, and holistic clinical insight.

This is where the ACP role clearly aligns with the needs of surgical teams. The ACP’s ability to independently assess, diagnose, treat, and discharge patients complements the dynamic, time-sensitive nature of surgical specialties.

ACPs in Surgical Specialties: Evidence-Based Benefits

1. Comprehensive Patient Management

ACPs offer continuity across the entire surgical care pathway. From pre-operative clinics to post-discharge follow-ups, their involvement improves patient flow and reduces delays. A study by the British Journal of Nursing (2023) highlights how ACPs in orthopaedic surgery manage arthroplasty patients from admission through to rehabilitation, leading to shorter hospital stays and improved patient satisfaction.

2. Enhanced Clinical Decision-Making and Autonomy

In fast-paced surgical wards, the presence of autonomous practitioners can ease pressure on overstretched junior doctors. The Royal College of Surgeons (2023) endorses the inclusion of ACPs as integral members of the extended surgical team, citing their contributions in clerking new admissions, adjusting treatment plans, and leading ward rounds.

ACPs can prescribe medications, order and interpret diagnostic tests, and escalate concerns independently. This capability makes them invaluable in on-call rotas and emergency surgical assessment units, where time-sensitive interventions are crucial.

3. Leadership, Mentorship and Education

One of the defining features of ACPs is their engagement across the four pillars of practice. In surgical departments, ACPs often take on educational roles, mentoring junior staff, medical students, and even ECPs. Their leadership is instrumental in driving service improvements, implementing evidence-based practices, and leading quality improvement projects.

An example from a London NHS Trust (NHS Jobs, 2023) describes ACPs leading post-operative care pathways and teaching sessions for nursing staff, which improved care consistency and reduced variation in surgical outcomes.

4. Workforce Sustainability and Service Resilience

The NHS continues to face recruitment and retention challenges, particularly within surgical specialties. ACPs provide a solution by offering continuity in teams often disrupted by rotational training posts. Their permanent presence ensures service stability and allows them to build deep expertise within their specialty.

According to ISCP (2020), surgical ACPs are increasingly being used to cover out-of-hours shifts, contribute to minor surgical procedures, and relieve pressure on core trainees. This flexibility supports both patient care and surgical training programs.

Why ECPs Fall Short in Surgical Specialties

While ECPs undoubtedly contribute to enhanced service delivery, their role is inherently limited in scope when compared to ACPs. The ECP framework lacks the autonomy, leadership emphasis, and breadth of clinical responsibility required in high-pressure surgical settings.

ECPs may excel in supporting roles—conducting observations, assisting with specific assessments, or delivering care under defined protocols. However, their inability to prescribe independently, lead complex assessments, or make autonomous clinical decisions restricts their utility in advanced surgical care. In environments where rapid clinical decisions can be lifesaving, the reliance on supervision or medical sign-off can introduce delays and inefficiencies.

That said, when ECPs undertake advanced training such as NMP and physical assessment courses, their contribution can increase significantly. They may assume more clinical responsibility and serve as a bridge between standard nursing roles and ACP-level expectations. However, without formal recognition as ACPs, these individuals remain in a transitional or extended role that can lack clarity and consistency across organizations.

A Strategic Investment: Why ACPs are the Future of Surgical Teams

Integrating ACPs into surgical services is more than just a staffing solution; it is a strategic investment in the future of patient-centred, sustainable surgical care. Their advanced competencies allow them to:

• Reduce patient waiting times by running independent clinics.
• Alleviate on-call and weekend pressures by covering critical care areas.
• Drive quality improvement through evidence-based practice.
• Support junior doctors and enhance multidisciplinary team working.

The Royal College of Surgeons (2023) explicitly acknowledges the benefits of ACPs, noting their ability to bridge gaps in surgical rotas and contribute to better clinical governance. Furthermore, ACPs embedded in surgical teams help reduce the over-reliance on locum doctors, offering financial efficiencies alongside improved care standards.

Conclusion: Empowering Surgical Services with ACP Expertise

In accordance with the Nursing and Midwifery Council (NMC) Code (2018), which highlights the importance of practising effectively, preserving safety, and promoting professionalism and trust, the distinctions between ACPs and ECPs discussed in this article are grounded in evidence-based practice and a commitment to high standards of care. ACPs exemplify these professional values through autonomous decision-making, leadership, and contribution to service innovation.

As surgical specialties evolve to meet the demands of an aging population, rising complexity of care, and persistent staffing challenges, the inclusion of Advanced Clinical Practitioners becomes not only beneficial but essential. Their ability to deliver high-quality, autonomous, and evidence-informed care makes them uniquely suited to the surgical environment.

While ECPs offer a valuable extension of nursing capabilities, their contribution is best suited to less acute settings or structured support roles. In contrast, ACPs bring strategic, clinical, and operational value to surgical services, acting as both expert clinicians and system leaders.

For Trusts seeking to future-proof their surgical services, investing in the development and integration of ACPs is a forward-thinking move—one that aligns with workforce sustainability, enhanced patient outcomes, and the delivery of safe, efficient surgical care.

References

Health Education England (2020) What is Advanced Clinical Practice? Available at: https://www.hee.nhs.uk/our-work/advanced-clinical-practice/what-advanced-clinical-practice (Accessed: 13. May 2025).

Royal College of Surgeons (2023) Advanced Clinical Practitioners. Available at: https://www.rcseng.ac.uk/careers-in-surgery/surgical-team-hub/surgical-team-roles/advanced-clinical-practitioners/ (Accessed: 15. May 2025).

Skills for Health (2024) Enhanced Clinical Practitioner Apprenticeship FAQs. Available at: https://haso.skillsforhealth.org.uk/wp-content/uploads/2024/02/2024.02.02-ECP-FAQs.pdf (Accessed: 13. May 2025).

British Journal of Nursing (2023) ‘The role of the advanced clinical practitioner in arthroplasty care’, British Journal of Nursing. Available at: https://www.britishjournalofnursing.com/content/advanced-clinical-practice/the-role-of-the-advanced-clinical-practitioner-in-arthroplasty-care (Accessed: 15. May 2025).

ISCP (2020) Surgical Advanced Clinical Practitioner Curriculum and Assessment Framework. Available at: https://www.iscp.ac.uk/media/1141/sacp_curriculum_dec20_accessible-1.pdf (Accessed: 14. May 2025).

NHS Jobs (2023) Surgical ACP Job Advert. Available at: https://www.jobs.nhs.uk/candidate/jobadvert/C9412-23-0705 (Accessed: 14. May 2025).

Royal College of Surgeons (2023) ‘The role of surgical care practitioners in the extended surgical team’, RCS Bulletin, Available at: https://publishing.rcseng.ac.uk/doi/full/10.1308/rcsbull.2023.41 (Accessed: 15. May 2025). Royal College of Surgeons (2023). Role of Surgical Care Practitioners. https://publishing.rcseng.ac.uk/doi/full/10.1308/rcsbull.2023.41