Deskilling the workforce
A large proportion of the NHS's budget is spent on its workforce, indeed this cost is three-fifths of total NHS providers' expenditure. With so many NHS organisations in deficit and seeking ways to save money, there are concerns that they may opt to employ lower skilled healthcare workers to cut costs.
The employment of lower skilled staff is also being driven by the shortage of fully qualified staff, including hospital doctors, nurses, and GPs.
A key component of the workforce plan published in June 2023 is an expansion of MAP (medical associate professional) roles, in particular physician associates (PAs) and anaesthesia associates (AAs). These roles require less training.
Billions spent on agency staff
The cost of staff has risen in recent years, due to increasing numbers and rising average cost per staff member employed. The major driver for this increased cost is spending on non-permanent staff.
In 2018/19 NHS trusts spent £5.8bn on temporary staff. This cost represents 80% of nurse vacancies and 90% of doctor vacancies being filled by more expensive agency or bank staff. Due to the pandemic this cost rose to over £6.2bn in 2019/20.
Since the pandemic, the NHS continues to increasingly rely on agency staff. In 2021/22, the NHS paid out £9.2bn on additional staff, of which £3bn was on agency staff, up 20% on the previous year. Accounts data published by NHS England in late 2023 shows this outlay increased to £3.5bn in 2022-23.
One in three NHS trusts paid an agency more than £1,000 for a single shift in 2021/22 while one in every six paid more than £2,000. NHS England and NHS Improvement, have said that agency prices should be capped at 55% above substantive pay rates, but this is obviously not happening.
In an effort to cope with an increasing shortage of fully qualified doctors, GPs and nurses, the NHS has sought ways to employ less skilled staff in roles that cover work that previously would have been undertaken by skilled doctors and nurses.
Employing less qualified staff will also cut down the overall costs for the NHS.
New roles in primary care do not improve care
A response to a severe shortage of fully qualified nurses and GPs in primary care has been the increased employment of non-medical staff with clinical roles. However, a study of over 6,000 general practices in England by researchers at the University of Manchester, published in August 2022, found the increased employment of such roles in primary care is linked to negative impacts on patient satisfaction.
The new roles includes social prescribers, clinical pharmacists, paramedics and physician associates.
Lead researcher Igor Francetic noted that:
"The introduction of new roles to support GPs does not have straightforward effects on service quality or patient satisfaction. In fact we provide substantial evidence of detrimental effects on patient satisfaction when some Health Professionals and Healthcare Associate Professionals are employed. Patient satisfaction is a crucial dimension of quality of care, as it contributes to individuals’ willingness to seek care through GPs."
The researchers concluded that overall there was ‘little evidence’ of any complementarity or substitution between different staff groups, suggesting that the additional staff were not freeing up GP or nurse time to do other work or making practices more efficient.
These new staff are being employed by GP networks in England via the additional roles reimbursement scheme (ARRS).
The quarterly figures, published by NHS Digital, show that 38,241 ARRS staff were working in general practices as of June 2022, up from 18,290 in March.
In July 2023, the use of Physician Associates (PA) was discussed in Parliament. A GP practice in North London had made the decision to stop employing PAs after an incident contributed to the death of a patient. The patient had believed the appointment she made at the surgery was with a GP, when it was with a PA. The patient's condition was misdiagnosed by the PA and she died of pulmonary embolism.
See below for a more in depth discussion of the role of PAs in both primary care and hospitals.
Training reduced
The lack of adequate numbers of fully skilled staff is leading to the remaining workforce being unable to keep up with training important for refreshing their skills and adding new ones.
A survey by baby loss charity Sands published in June 2022 found that most midwives across 117 UK health Trusts and Boards are expected to undertake bereavement care training in their own time.
Only 49% of NHS Trusts and Boards surveyed by Sands provided bereavement care training to staff and only 12% of those who did allowed for that training to happen during working hours.
RCM’s Chief Executive Gill Walton said:
“What we are seeing far too often is many midwives and maternity support workers (MSWs) booked to attend vital training across a range of areas, including safety, are having to postpone. Because of understaffing, they have no choice but to stay on shift to plug the staffing gaps and to care for women and their babies. In the long run this can have serious implications for the quality and safety of care if training is not kept up to date. It’s a vicious circle. so many reports say midwives need more training, but we aren’t given enough midwives to enable this to happen proficiently.”
HCAs versus nurses
There are serious concerns that there is a move to replace registered nurses with less skilled and cheaper healthcare support workers (HCSWs), such as healthcare assistants (HCAs) and Physician Associates (PAs). There is a considerable body of evidence that the risk of adverse patient outcomes, including death, is lower in hospitals that provide more registered nurses to care for patients on inpatient wards. The studies have involved hundreds of hospitals and millions of patients from around the world. A 2023 paper published in the BMJ Quality & Safety - Nurse staffing and inpatient mortality in the English National Health Service: a retrospective longitudinal study - by researchers at the Imperial College Business School concluded that "RN staffing and seniority levels were associated with patient mortality. The lack of association for HCSWs and agency nurses indicates they are not effective substitutes for RNs who regularly work on the ward."
BMJ Open research of 137 NHS acute trusts from February 2016 suggested a link between a higher proportion of HCSWs per patient and a rise in mortality.
Peter Griffiths, lead researcher on the study and Chair of Health Services Research at the University of Southampton, noted in an editorial in the Nursing Times that the study “does clearly show that any policy that regards registered nurses and support workers as interchangeable [...] is ignoring a vital difference between the roles and capabilities of different workers on the wards.”
A survey of healthcare assistants in 2018 revealed that two thirds of HCAs are performing tasks usually carried out by nurses, such as giving patients drugs or dressing wounds. 63% of HCA respondents also reported that they were providing patient care with worryingly little help from doctors or nurses.
These results have sparked further concern that patients may be receiving inferior care that could potentially be unsafe. Unison noted in 2018 that HCAs were being overworked without adequate training or supervision. More prevalently HCAs are filling rota gaps due to the 40,000 shortfall of nurses.
The new nursing associate role
In 2016, plans to create a new non-registered nursing associate role launched. The aim was to bridge the gap between HCAs and nurses. The RCN and Unison warned that this was diverting attention away from the serious problem of a shortage of registered nurses. This role should not be a substitute for registered nurses.
Since, the Nursing and Midwifery Council have set out standards and regulations for the nursing and nursing associate programmes. They opened their register for nursing associates in January 2019. Additionally, as of July 2019 new students can only start training for the role on approved programmes.
Physician associate roles
In May 2016 The Nuffield Trust published a report entitled Reshaping the Workforce commissioned by NHS Employers. It detailed the potential for training nurses and other support staff to take the pressure off doctors as a way to tackle the hospital staffing crisis. The extra training would be to give nurses and others "advanced practice roles" or "physician associate status" as a relatively quick solution to the current shortage of doctors.
The publication of the report caused alarm among doctors and patient groups. Katherine Murphy, the chief executive of the Patients Association, said: “The proposed new roles and extra responsibilities for existing staff should not be adopted as a ‘quick fix’ solution to the complex staffing problems within the NHS, nor be seen as a cheaper alternative to highly qualified staff."
The BMA gave a cautious response to the report noting that the report was "a sensible assessment of the current situation that the NHS workforce is in....however, while we support the upskilling of the existing workforce and the introduction of new roles to assist with patient need, this should not be done at the expense of good quality training for doctors or, indeed, doctors themselves."
PAs a key component of workforce plan
Despite reservations from many organisations, the roles of medical associate professionals (MAPs) within the NHS, primarily PAs and Anaesthetic Associates (AAs), became a key component of the workforce plan published in June 2023.
The workforce plan contained a pledge to increase PA numbers to 10,000 by 2036-37 ( from around 3,000 at present) and AA numbers to 2,000 (from around 120 according to recent figures).
Tragic cases highlighted by the media
The increasing use of PAs hit the headlines in 2023 when the mainstream media picked up on two tragic cases of deaths due to mistakes made by PAs in GP surgeries.
Emily Chesterton died in November 2022 after a PA failed to diagnose and treat her deep vein thrombosis and pulmonary embolus at two consultations and did not seek advice from a GP, and Colleen Howe, died in 2023 from aggressive breast cancer after delays caused by a misdiagnosis from a PA at her GP surgery.
These deaths highlighted the increasing use of PAs in GP surgeries and the lack of public understanding of the role. In both cases neither patient was aware that they were not seeing a professional that was not as well qualified as a GP.
Other social media discussions and media headlines have focused on PAs being used in positions that would previously have been the preserve of doctors. Recent headlines include the BBC revealing that Birmingham Children’s Hospital was using PAs in senior roles in the liver unit with a consultant on call. PAs have worked at Birmingham Children’s Hospital for 10 years but the BBC reported that it saw rotas which show them on tier two, normally a rota for senior doctors (registrars).
The discourse surrounding PAs on social media has been highly critical and acrimonious. The BMA has accused PAs of presenting themselves as GPs, doctors and consultants, and noting that there have been reports of medical students losing out to PAs for training. Plus there are reports of situations where PAs appear to be carrying out work that is outside of their remit.
Training
Much of the media discussion has focused on the level of training that PAs/AAs receive before being allowed to work with patients.
PAs work as part of a multidisciplinary team with supervision from a named senior doctor (GMC registered consultant or GP), providing care to patients in primary, secondary and community care environments. AAs work under supervision in a similar way but only in the anaesthesia setting.
To qualify as a PA in the UK, students had to have completed a bioscience-related first degree and then a postgraduate (level 7, i.e. a master’s level) degree in physician associate studies that takes two years. However, there are now undergraduate integrated Master of Physician Associate Studies programmes available that require A-levels or equivalent for entry and there is also a level 7 apprenticeship.
Registered healthcare professionals, such as a nurse, allied health professional or midwife can also apply to become a PA.
A PA can carry out a wide variety of work, including taking medical histories from patients, carrying out physical examinations, carrying out diagnostic and therapeutic procedures, and seeing patients with undifferentiated diagnoses.
However, they can not prescribe or request ionising radiation (eg chest X-ray or CT scan).
Regulation
In 2015 the Faculty of Physician Associates (FPA) was established by the Royal College of Physicians to set standards and to oversee the PA-managed register. This register is voluntary.
Currently, PAs and AAs are not subject to any form of statutory regulation, but this is due to change. In July 2019, the Department of Health and Social Care (DHSC) asked the General Medical Council to regulate MAPs, including PAs and AAs.
In February 2023, the DHSC launched a consultation on PA regulation, which included extending prescribing responsibilities to PAs. This has closed now and regulation is expected for the PA and AA profession by the end of 2024.
What are the issues with PAs?
The debate on the use of PAs and AAs in the NHS has highlighted a number of issues including:
- the pay differential between PAs and junior doctors, with newly qualified PAs earning around 35% more than junior doctors despite the difference in experience and responsibility;
- a reduction in training situations for medical students;
concerns over patient confusion as to whether they are seeing a PA or doctor; - and, the increasing use of PAs in GP surgeries in place of GPs.
To reduce patient confusion, the BMA wants a return to the title physician assistants. Anaesthesia associates (AAs) were similarly previously known as physician’s assistants (anaesthesia). Patient confusion will also not be helped, the BMA feels, by the planned move for the GMC to regulate PAs and AAs.
But the BMA’s objections to the current expansion of PAs and AAs goes far deeper that titles and regulator:
“Their use and planned expansion challenges what it means to be a doctor, reflects how the medical profession has been devalued, and demonstrates how the health system is seeking to undermine it in favour of colleagues with less training, skills and expertise.”
The BMA opposes the planned expansion of PA and AA roles, and the granting of prescribing rights following regulation, unless it can be demonstrated that the concerns have been addressed.
In November 2023, the BMA called for an immediate pause on all recruitment of Medical Associate Professionals (MAPs) in the UK including PAs and AAs across general practice and PCNs.
Doctors from across the UK who make up the BMA’s UK Council passed a Motion calling for the moratorium on the grounds of patient safety. They want the pause to last until the government and NHS put guarantees in place to make sure that MAPs are properly regulated and supervised.
Previously, in late October, the BMA junior doctors committee and GP registrars committee published a statement on MAPs (medical associate professionals), noting that:
“in response to the manufactured workforce shortage of nearly 10,000 doctors, the rapid expansion of medical associate professionals (MAPs)…is detrimental to the provision of high-quality healthcare and represents a long-term risk to patient safety.”
The Royal College of Anaesthetists convened an extraordinary general meeting in mid-October at which over 90% voted to pause the rollout of AAs.
The GMC has written to NHS England, according to a report in HSJ, asking it to: “Directly tackle the perception that there is a plan for the health services to ‘replace’ doctors with PAs or AAs by convening and leading a system-wide discussion on an agreed vision for these roles.”
In December 2023, the BMA published a survey with over 18,000 responses from doctors, which found the majority of doctors believe that the way PAs work ‘present a significant risk to patient safety’.
In all, 87% of doctors who took part said the way AAs and PAs currently work in the NHS ‘was always or sometimes a risk to patient safety’ and 86% reported that they felt patients ‘were not aware of the difference between these roles and those of doctors’.
The BMA stated that the results of the survey are more evidence that the "Government’s plan to regulate PAs and AAs by the GMC – the doctors’ regulator - are ill-thought-through and will likely further blur the lines between doctors and other roles in patients’ minds."
Despite all the opposition, the necessary legislation for the GMC to regulate PAs and AAs was passed by the government in January 2024.
The first half of 2024 and the run-up to the election on 4 July 2024 saw the debate on PAs and AAs escalate. Details can be found in The Lowdown article - Battles Rage over Physician Associates.
In March 2024, the Royal College of Physicians (RCP) held an emergency general meeting (EGM) – only its second such meeting in 515 years.
The EGM was shown slides by the RCP leadership, including Dr Sarah Clarke, RCP president, that gave a completely misleading picture of the results of a survey of members’ views. The EGM presentation argued that 66% of doctorswho currently work with PAs were ‘neutral or positive’ about PAs: however when the raw data was eventually published it revealed that just 30% had responded positively, while 42% were negative and 27% had been neutral.
More than 80 RCP fellows declared a lack of confidence in the college’s leadership over its handling of the PA debate, and five senior officers wrote to the college to demand Dr Clarke’s resignation because she had ‘lost the confidence of the RCP membership’.
In late June 2024, Dr Sarah Clarke, president of the Royal College of Physicians (RCP) announced she will step down.
Dr Clarke’s statement made no mention of PAs, or of her support for the RCP’s Faculty of Physician Associates, set up in 2015. The statement claimed she would “step aside, […] following a challenging time for the college.”
On the same day as Dr Clarke explained her departure to the RCP Trustees, the Royal College of General Practitioners (RCGP) announced a toughened stance on PAs, urging GP practices across the UK to:
“halt the additional recruitment and deployment of PAs into general practice until PAs are regulated and practices are in a position to implement the RCGP’s forthcoming guidance on scope of practice, induction and supervision.”
This recommendation is based on ‘concerning findings’ from the RCGP’s recent consultation, which surveyed over 5,000 GPs and found that a massive 80% believe the use of PAs in general practices has a negative impact on patient safety.
The RCGP has further advised partners in practices that are already employing PAs to ensure they do not see undifferentiated patients and that daily supervision time is built into timetables.
However this new guidance is in conflict with NHS England’s guidelines, which makes it a condition of funding to cover appointment of PAs that they must “provide first point of contact care for patients presenting with undifferentiated, undiagnosed problems.” (page 91)
The Royal College is also opposed to the registration of PAs being handled by the same body, the General Medical Council (GMC), that regulates doctors.
This latest toughening of the RCGP’s stance on PAs follows months of pressure from disgruntled GPs who were uncomfortable with the way in which a new group of “medical professionals” had been allowed to threaten the jobs of fully trained GPs and potentially undermine the safety of services.
Meanwhile NHS England is offering extra funds to subsidise PAs and other additional roles, but not to employ GPs (who are increasingly facing unemployment). The result has been increasing pressure on the BMA to take more proactive measures to block any further moves that threaten to substitute cheaper, minimally-trained, PAs for fully-trained GP members.
New BMA advice now states that sessional GPs’ job descriptions should not include supervising non-doctors unless this is “expressly and mutually agreed;” and that GPs should not be expected to sign prescriptions, request investigations or make referrals based solely on the clinical assessments made by ARRS staff.
The union adds that if a sessional GP does agree to supervise multidisciplinary team/ARRS roles as part of their agreed job plan, they must be allocated sufficient time to safely perform this role, and receive appropriate supplementary pay.
The BMA has published a national scope of practice which (like the latest RCGP guidance) makes quite clear that PAs should never see ‘undifferentiated’ patients in a GP setting.
In late June 2024, the BMA announced a legal challenge to the way the GMC has handled the question of regulating PAs and AAs, resulting in a “dangerous blurring of lines for patients between highly-skilled and experienced doctors, and assistant roles.”
There is, indeed, no logic in the GMC being the regulatory body, since the postgraduate qualification of PAs and AAs makes their status quite unlike doctors, and much more akin to the other non-medical professionals like Occupational Therapists, Physios and Radiographers, who are all covered by the Health and Care Professions Council (HCPC).
Other areas of concern
The workforce plan announced in June 2023 contained plans to shorten the five or six years taken to earn a medical degree, in an effort to less experienced students on to the wards sooner. There are also plans for more “apprenticeship training” of doctors.
Professor Azeem Majeed, a GP and head of primary care and public health at Imperial College London, told the i paper that clinicians have concerns over the safety of the scheme.
“An apprenticeship scheme would put patients at risk if the doctors it produces were not as well-trained as those who were trained by a conventional medical course."
During the Covid pandemic in July 2020, an audit was triggered after many medical professionals recruited to work in the clinical division of the 111 service said they did not feel “properly skilled and competent” to fulfil the critical role. an investigation found that 60% of calls did not pass the criteria of “demonstrating a safe call”.
