Wider use of doctors will increase inequality, say British doctors

Doctors are warning the UK’s medical regulator that wider use of doctors in the NHS could jeopardize patient safety and lead to greater inequalities in care in deprived areas that struggle to recruit GPs.

The government’s plan to recruit 10,000 physician associates — health care professionals supervised by doctors — has angered many clinicians who say the roles are poorly defined and pose a potential threat to patient safety.

The General Medical Council (GMC) will start supervising doctors and anaesthetists who also work under the supervision of doctors from December.

The doctors’ union, the British Medical Association, announced last week that it was seeking a GMC investigation into the “dangerous blurring of the lines” between doctors and medical assistants. It argues that doctors and anaesthetic assistants should be regulated, but not by the GMC.

Other professional membership bodies want clarification of the roles of practitioners. The Royal College of General Practitioners (RCGP) told the GMC that regulation was an “important step forward” but that the scope of practice needed to be developed urgently.

In a contribution to a GMC consultation on regulation, the RCGP said: “There is concern that the use of (physician assistants) in deprived areas, where it is often difficult to recruit or retain GPs, could lead to inequalities in patient care and -Results.” An RCGP survey found that eight out of ten respondents considered negative impacts on patient safety to be a challenge when deploying junior doctors in general practice.

Prof Kamila Hawthorne, chair of the RCGP, said junior doctors should not be substitutes for GPs. She said: “We need to see more done to increase the number of GPs across the country, but particularly in areas of higher poverty.”

The Hospital Consultants and Specialists Association told the GMC that the lack of clarity over staff roles “will put patient safety at risk”. It said: “The current titles of the roles, the lack of clarity over the scope and the ambiguity over supervision make it very easy for (staff professions) to be mistaken for doctors and for misunderstandings to arise over the level of skills and experience.”

Trisha Greenhalgh, professor of primary care sciences at the University of Oxford, said doctor staff did not have the training to be deployed on the frontline caring for patients with undiagnosed conditions. It was “the worst governance problem I have ever seen in healthcare in Britain”.

Junior doctors, who can work in general practices and hospitals, have been working in the NHS since 2002 and nurse anesthetists since 2004. They cannot prescribe medicines but can carry out physical examinations and diagnostic procedures. They are trained in a two-year postdoctoral program.

There are more than 3,300 doctors or anesthetists in the NHS in England. The NHS Long Term Workforce Plan A report published last year set a target of having 10,000 physicians and 2,000 anesthesia staff by 2036-2037.

Research from Britain and elsewhere has suggested that physician assistants can deliver safe, cost-effective care, but these roles have sparked bitter debate in the medical community.

Sarah Clarke resigned as president of the Royal College of Physicians this month after members said the leadership failed to take action on evidence that physician associates were “systematically replacing doctors” and had failed to respond properly to patient safety concerns.

The potential confusion over doctors’ roles was recently highlighted by a poster on the Bradford District and Craven Health and Care Partnership website, which depicted a junior doctor saying: “The doctor will see you now”.

It is an offence under the Medical Act 1983 to use the title doctor for someone who is not a registered medical practitioner. The partnership said there had been “genuine errors” in their promotional material and that they were conducting an internal investigation to understand how these errors had been made.

Stephen Nash, a physician associate and chief executive of United Medical Associate Professionals (UMAPs), said: “These roles provide greater access to patients who would otherwise not be able to see a doctor. When we see patients with red flag symptoms, we can work with colleagues to stabilize the patient and refer them to people who need to see them. We absolutely have the training to be the front line.”

Nash denied that medical staff posed a safety risk, saying that in areas where it is difficult to recruit GPs, they could improve access to care.

UMAPs said many doctors and anesthetists were experienced former nurses, radiographers and other health professionals. Mandatory registration was a “welcome step”.

Lord Bethell, a former health secretary, said: “Modern medicine relies on teamwork involving a combination of people with different skills. There is clearly a role for physician assistants to meet the growing demand for healthcare services.”

NHS England said: “The NHS has always made it clear that physician associates are not a replacement for doctors. The NHS has also recently issued guidance on the appropriate use of these roles, which makes it clear that physician associates should provide support and carry out tasks under supervision of doctors to help them do their work.”

The Royal College of Physicians said it had accepted recommendations from a working group calling on NHS England to limit “the pace and scale” of the rollout of physician associates.

The college acknowledged significant concerns about patient safety. It said it would work with other national bodies to contribute to a database of evidence on the work of medical staff.