SHA Cymru Meeting on Physician Assistants 30/1/24
Naming Conventions
Use of language is critical to avoid confusion about professional roles and responsibilities.
The language must be standardised across all roles in all professions. It must also be a terminology that the public understands.
The terms Associate is ambiguous and can be read to be on a par with qualified doctors.
We propose the term “Medical Assistants” (MAs) or Medical Assistant Practitioners (MAPs) should be used as the wide generic description of this professional grade with the use of GP Assistants, Cardiology Assistants etc as appropriate. This clearly denotes that it is an assistant role and not a partner or equivalent role.
Dental associates are actually qualified dentists working in practices, but do not have a partnership. Similarly legal associates in law have a legal degree . The use of the title “ physician associate “ is bound to be confusing when compared to other professions.
Overview
Fifty years ago, doctors took bloods, put up drips, were the sole managers of diabetes and phlebotomists were virtually unknown. Time moves on with clinical roles changing and evolving. But this needs to happen in a structured manner, assessing the risks and ensuring that training, certification, and role clarity are all fit for purpose.
New practitioners, such as MAPs, have a role as highly trained professionals can concentrate their skills and expertise at an appropriate level of need.
However, there is understandable public confusion about the roles and what level of expertise and experience they can expect from these new roles.
Equally, avoidable patient deaths have been attributed to a lack of training and experience of MAPs.
The public can attribute more experience, expertise and consequently more trust in the role/person than is appropriate.
In England GP Practices are effectively bribed to take MAPs on as they represent no cost through the Additional Roles Reimbursement Scheme. This is distorting the market as they are paid more than some junior doctors and there are reports of GPs not getting GP jobs because roles are filled by MAPs..
Medical students need both training and practice to qualify as a doctor. We must not be in a position where the enthusiasm to train MAPs compromises the quality of medical education.
We note that there are already two universities in Wales that are training MAPs However the Welsh Government has yet to publish a quantified long term workforce plan which clarifies the needs and role for such graduates. At the moment they seem to be deployed on an opportunistic and ad hoc basis.
The role of MAPs was developed in the USA in response to cost pressures of health insurance provision. There is deep concern that the uncritical importation of these roles is part of the privatisation / insurance model of healthcare which is facilitated by the Health and Care Act. This Act which also gives the UK Government statutory powers to deregulate each professional regulatory body.
The UK Government Consultation on MAP Regulation.
This is one of the most obtuse and respondent hostile consultation exercises ever produced. Few will manage to wade through the over-verbose, unwieldy, jargon ridden document. This will inevitably mean that any response will be biased toward those who have the time and commitment to engage with such an impenetrable process.
Why MAPs?
This is a shorter route to getting staff into healthcare than the normal one. At the time of a staffing crisis this may look very attractive to some policy makers, but it is fraught with short-term and unacceptable risks for the general public.
There is a role for the delegation of clinical tasks to less qualified practitioners, but it must be done as part of team led by a fully trained medical specialist.
From a trade union point of view, MAPs could be seen as undermining current professional structures and, in the process, erode the terms of service of professional groups such as the Junior Doctors and GPs. This will have major Implications for future recruitment and retention.
MAPs are no replacement for a lack of workforce planning. We agreed that a proper 10-year workforce plan must be in place with a target list size for GPs of 1,200 per whole time equivalent.
We welcome that MAP roles may provide a stepping stone to more advanced qualifications.
There needs to be some thought to the evolution of the role over 10 years in the light of practice experience. But the assumption must always be in the context that we need fully qualified doctors, nurses, physiotherapists etc. rather than ever more MAPs to plug workforce shortages.
We note that there are nursing associates and physiotherapy associates who can do a good and useful job. However, we are concerned that there are some unregulated support workers in these professional groups. This must be addressed.
Role and Scope of MAP Training
The role needs to be very clearly defined, limited, and should only include a defined set of tasks and competencies which should be based around Band 7.
Training needs to include dealing with patients, their families and informal carers.
We believe it is much too early allow MAPs have prescribing powers.
Prescribing should be done by medical or nurse prescribing colleagues and properly overseen.
Indemnity lies with the GP practice or hospital and competencies must be signed off.
The MAPs’ role must not subject to local discretion and flexibly used to plug gaps in particular areas. This would be an abuse of the individuals involved who would find themselves in this unacceptable situation of working beyond their competence while undermining patient safety and public protection.
Regulation
There was general agreement that the MAPs should be regulated by the GMC but there was a case that other regulators e.g. HCPC, could be involved.
The regulating body must be best placed to make judgements from the point of view of professional oversight, on training and keeping competencies reviewed and up to date.
In a profession where whistle blowing can be very difficult, there must be openness in terms of assessing and pointing out risks with the way MAPs are being trained and deployed.
Dealing with Patients
As already noted, training needs to include dealing with patients, their families and informal carers.
“Hello, my name is….” Should have added after it, “and my role is”.
There must be increased understanding by the public on the titles and experience associated with roles in the NHS. Ministers who call Junior Doctors “apprentices” do not help. This is why a proper public consultation process is essential.
Conclusions
The meeting was not against having MAPs in Wales within the context of a proper workforce planning and proper regulation.
What we really need is more qualified doctors and nurses, not a less qualified stop gap role potentially undermining patient safety.
The naming convention needs changing to Medical Assistants (MAs) or Medical Assistant Practitioners (MAPs)
While there is a general understanding of the word “physician” it is nowhere as well understood as “medical”. We strongly recommend that the word “medical” is used instead of “physician”. The word “associate” is likely to denote a much higher level of expertise to the public. Patients must always have the right to know and understand the level of expertise of the person who is treating them. We strongly recommend that “associate” is replaced by “assistant”.
On balance, should be regulated by the GMC.
Must have clear role, training and competencies and must always be part of a team, not working independently. Prescribing responsibilities would be premature at this stage.
The role must be defined across the profession with no ability to change or vary locally.
When meeting patients, they should always identify what their role is. There needs to be more understanding by the public of the roles/ranks within healthcare and what they signify in terms of education, training, and experience.
Proper workforce planning on a 10-year horizon is vital. We also need to consider where these roles will be in 10 years’ time.