Enhanced practice refers to a level of physiotherapy practice where graduate professionals have moved beyond the novice level of practice.
Introducing enhanced practice
Enhanced practitioners are the largest group within the physiotherapy workforce, delivering the majority of healthcare services. Enhanced level practitioners do not work at the level of advanced practice, but they draw on a substantial knowledge base, understanding and experience to manage complexity and risk autonomously and proficiently.
This level of practice is reflected in policy within England (NHSE Long Term Workforce Plan, 2023) and through the recent development of enhanced practice apprenticeships for many of the allied health professions.
In Wales, the Professional Framework for Enhanced, Advanced and Consultant Clinical Practice (2023) describes this level of practice and an accompanying portfolio resource can support demonstration of knowledge, skills and capability at this level.
This statement articulates the CSP views on enhanced practice and applies across all nations and includes our position on the newly developed profession-specific enhanced practice apprenticeship for physiotherapy in England.
Recognising enhanced practice
The CSP recognises enhanced practice as a distinct level of practice within the career pathway of the physiotherapy profession and this has been reflected in our forthcoming career framework. We value the contribution those working at a highly skilled enhanced level of practice within the physiotherapy profession make toward delivery of safe, efficient and high-quality patient care. The CSP supports physiotherapists who choose to stay working at an enhanced level of practice as a career destination and those for whom enhanced practice is a transition period toward advanced and consultant level careers.
In all nations, the CSP wants to see greater investment in funded and sustainable training pathways for all career stages, with an emphasis on development across the four pillars of practice throughout. This approach will enhance patient care and support better career progression for the physiotherapy workforce.
We therefore welcome this commitment from NHS England to optimise the professional skills and capability of this sector of the workforce through the development of the physiotherapy enhanced practice apprenticeship.
The CSP will be making the case for similar commitments to post-graduate training and education pathways for our members in Scotland, Wales and Northern Ireland as part of our policy commitments around apprenticeship/earn to learn models of education and workforce development.
Enhanced practice apprenticeship in England/Enhanced practice education
Model of delivery
The CSP supports the development of the enhanced practice apprenticeship offer in England. This is because it provides a clearly structured, accredited and funded route of training and skill development with ring-fenced time for off-the-job learning.
This will support career progression through a clearly articulated pathway and therefore could also support retention.
The CSP were stakeholders in the development of the physiotherapy schema and model curricula, which provide useful guidance to training providers to support the development of their education offer at this level.
The CSP holds that the enhanced practice apprenticeship funding band should be kept under review to ensure the investment available is sufficient for the education providers to deliver a high-quality programme.
The CSP’s view is that there should be a range of funded education and training opportunities open to physiotherapists to both reach and develop within the enhanced level of practice.
Funding routes outside the apprenticeship levy should also be developed or sustained to increase equity of opportunity.
This is because not everyone is eligible to access apprenticeships and it is not always appropriate for all types of learners or learning.
Enhanced practice education content
The CSP believes that education providers should adopt the national guidance on how to develop their enhanced practice curricula as we believe this will support standardisation and quality.
The CSP advocates that education providers and employers work together to determine the appropriate content for their enhanced practice programme.
This is to develop skill capacity within the specialist areas of physiotherapy that will best meet population and workforce needs of their local system.
Academic level of enhanced practice training
The CSP supports physiotherapy enhanced practice education to be delivered at level 7. This is because the majority of physiotherapy pre-registration education is delivered at level 6, thus level 7 learning offers members the greatest opportunity to develop a higher level of knowledge, skill and capability which will result in increasing efficiency and quality of care.
For the individual, this could result in a higher-level academic credit as the apprenticeship standard in England does not have a mandated qualification. This may be helpful for them in their future careers.
Progressing to advanced practice
Enhanced and advanced practice are on a continuum but do represent distinct levels of practice. The CSP believes this should be clearly articulated and reflected within the specification of education programmes.
Education providers should consider carefully how any education delivered at an enhanced level of practice can later be integrated into an advanced education pathway and what, if any, additional learning may need to be demonstrated to provide assurance that the learning meets the greater requirements of advanced practice.
Education providers must be explicit about any recognition of prior learning (RPL) arrangements so members are clear how any academic credits gained from enhanced practice study can or cannot be used for future advanced practice training routes.
Employers and members should seek this clarity to ensure individuals make the correct decisions for their future career plans and aspirations.
Profession-specific learning
The CSP embraces multi-professional learning where there are shared learning objectives across professions, recognising this reflects both the contemporary multidisciplinary model of service delivery and population health needs.
However, to meet the training needs of the physiotherapy workforce, we believe physiotherapy-specific learning should be a central part of this apprenticeship and any other enhanced practice training. This has been recognised through the development of profession-specific model curricula.
We would encourage education providers to create flexible offers of delivery to meet the specific expertise requirements of some areas of practice for the profession where there may not be sufficient density of learners within a small geographical area.
System support
This is a shift in approach to training and education for a significant part of the physiotherapy workforce. The CSP therefore believes individuals, employers, systems and education providers will need support to both understand more about what enhanced practice is and subsequently to operationalise the apprenticeship or other education route.
To ensure quality and adherence with regulations around apprenticeships for example, implementation must be carefully planned at a local level with due consideration of educator, supervisor and mentorship capacity and capability (see below).
This support should be provided nationally and regionally on an AHP-wide and profession specific basis as required. For the apprenticeship route, particular attention will need to be paid to ensure there are sufficient End Point Assessment organisations in place.
Work-based learning, mentorship and supervision is a critical requirement of an apprenticeship model. The CSP recognises that mentors are often also practice educators to another part of the workforce, such as learners on pre-registration courses.
Employers will need to review and potentially allocate increased resources to enhance and support their mentor, supervision, and educator workforce.
This investment should support structured training and allocate dedicated time within job plans as a standard practice to fulfil this essential aspect of their role.
The CSP also holds that the capacity for pre-registration student placements must not be compromised by the introduction of enhanced practice apprenticeships or other training routes.
This risk can be partially mitigated by workforce and placement planning at system level and investment in the appropriate educator and supervisor workforce.
Equity, diversity and belonging
The CSP expects employers to operate equitably and inclusively when identifying appropriate staff for training and education opportunities, including the enhanced practice apprenticeship. This includes holding routine career conversations with staff as part of their personal development reviews.
We believe this should start as early as the newly registered preceptorship stage of a clinician's career to ensure staff have clear sight of the career opportunities that lie ahead.
We welcome the explicit inclusion of EDB considerations within the NHSE schema documentation.
First Contact Physiotherapy (FCP)
Whilst the schema from NHSE refers to first contact practitioners working at an enhanced level of practice, the CSP holds its longstanding position that FCP is a role that requires advanced practice clinical skills.
This is also a requirement for the ARRS funding scheme in England and is widely used within job descriptions for FCP posts in England, Scotland, Wales and Northern Ireland.
However, investment in enhanced practice education pathways may well support the pipeline supply