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Competence and curriculum framework for the medical care practitioner

10 February 2006

Dear Mr Standfield

Thank you for inviting the BMA to comment on the curriculum framework that is proposed for medical care practitioners.

The BMA acknowledges that there are a number of non medically qualified practitioners currently undertaking roles similar to those envisaged for medical care practitioners. However, we have major concerns about the proposed development and expansion of this grade not least because we believe some crucial questions remain unanswered. It seems to us that a curriculum is being proposed for a grade whose function is unclear.

We would, therefore, ask for further consultation with the profession on the way forward for this group of practitioners, including in other specialties, and for the regulatory framework for this grade to be established before there is any expansion in their numbers and responsibilities.

Whilst we object to the use of the term medical care practitioner, we have used it throughout our response for the sake of clarity.

Our detailed comments are attached.

Yours sincerely
Sally Watson
Director of Representational and Political Activities

Competence and curriculum framework for the medical care practitioner
The BMA has always valued the work undertaken by nurse practitioners, assistants in surgical practice (and other branches of medicine) and other non-medically qualified practitioners. We acknowledge that these roles should be formalised and could be developed further. Any development, however, must maintain and enhance patient care and safety. Our comments have been produced with this principle in mind.

There is a need within the health service to identify the requirement for medical care practitioners and how the role will benefit patients and service delivery. Research conducted by Moorthy et al [Go to note 1] in response to the expansion of the surgical care practitioner role concluded that patients prefer to be operated on by medically qualified members of a surgical team and that broadening or extending the role of non medically qualified members of the surgical team to perform basic procedures was not needed. We would therefore call for greater engagement with the public to ensure that the extended role proposed in ‘The Competence and Curriculum Framework for the Medical Care Practitioner’ is genuinely required and that it fulfils patient needs and expectations.

A prerequisite for the expansion in the numbers and roles of non medically qualified practitioners is that it should not compromise medical student or junior doctor training. If medical care practitioners will be performing similar duties to junior doctors under consultant supervision then we seek assurances that medical care practitioners will not be competing for procedures and teaching time with medical students or junior doctors in training. Such competition, we believe, will further limit education and training opportunities for doctors. This will undoubtedly have implications for the future delivery of healthcare and development of a service that fulfils patient need.

There is a need for evidence on medical care practitioners which includes an evaluation of the medical care practitioner as a concept; we believe this should include an evidence base to support the projected number of practitioners that will be trained. We recognise that a number of non medically qualified practitioners with extended roles are already employed in NHS trusts. We would nonetheless welcome evidence of their effectiveness from current healthcare practitioners and those interested in healthcare training as well as evidence that shows a real demand for more such posts.

The curriculum framework for the MCP as a basis for the development of educational programmes
1. We believe that the ever increasing and changing nature of the demands placed upon the NHS and healthcare practitioners working within it requires the development of a flexible workforce. We acknowledge that non medically qualified practitioners with extended roles could play an increasingly important part in that workforce.

2. We recognise that the skills of non medically qualified healthcare professionals differ from those of medically qualified practitioners and that a diversity of skills can enhance patient care. The skills of both medically and non medically qualified practitioners should complement each other rather than compete. Currently the skills of doctors in training are not being used to best effect; some tasks that could be performed more appropriately by other healthcare professionals are being performed by doctors, in particular doctors in training. It is right first that the possibility of enhanced roles for non medically qualified staff be investigated, second that the tasks that they would be expected to undertake be properly identified and defined and that third the relationship of such roles with the existing healthcare team should be clarified.

3. The BMA is concerned that medical students and doctors in training will compete for the same education and training opportunities as medical care practitioners (both those trained and those in training). We are also concerned that such increased competition may further limit these opportunities for doctors in training and that they may have difficulty in achieving required levels of competency in medical procedures as a consequence. Furthermore the similarities between the two roles raise concerns about fulfilling the aim of a consultant delivered service, i.e. patient care that is provided by fully trained doctors. We seek your assurances that healthcare delivered by doctors will not be compromised.

4. The proposals do not appear to recognise that additional time will be needed by medically qualified practitioners for teaching both medical care practitioners and doctors in training. This in turn will have significant implications for service delivery. The delivery of the training and education requirements of doctors in training, already under pressure through the first stage of the implementation of the European Working Time Directive, will increase in intensity with the implementation of Modernising Medical Careers and the reduction in junior doctors working hours to 48 in 2009. We are concerned that the proposals will not be compatible with this situation and we would therefore welcome assurances that these concerns will be addressed before they are implemented in full.

5. The knowledge base suggested for the curriculum appears to indicate that the authors believe there may be scope to expand further the role of the medical care practitioners. We are concerned that medical care practitioners may, in the future, undertake procedures and tasks outside the remit of the original proposals. We would welcome your assurance that this is not the intention.

Entry routes to the MCP programme
6. We note that the length and academic level of individual programmes will vary. We believe that all medical care practitioners should be required to attain nationally agreed standards of competency which will allow them to practise competently in all aspects of their role. Variations in length or academic level should only enhance or build upon the nationally agreed standards of competency. We seek assurance that all medical care practitioner trainees will under go the same rigorous training to ensure that they provide a consistent standard of care and that patients will be able easily to recognise the training level of the practitioner caring for them.

7. Furthermore, doctors in training are required to undertake a rigorous medical training for five years or more prior to registration and incur significant levels of debt [Go to note 2]. The proposed entry route to training for the extended care practitioner may be seen as more attractive than that for doctors. This would have serious implications for the long term provision of healthcare by practitioners who are medically qualified.

8. If medical care practitioners are similarly qualified to doctors in training there is concern that the NHS will increasingly seek to employ non medically qualified practitioners to undertake work traditionally within the remit of doctors in training. This does not seem practical in the context of the current over supply of junior doctors in the job market and will again undoubtedly have implications for the longer term future delivery of healthcare. As alluded to above, we would like to see a reduction in the reliance on service delivery by doctors in training as we believe that patient care is best delivered by fully trained doctors.

Should arrangements be put in place to assimilate practitioners who meet the competences of the MCP into the regulatory process?
9. We note from the Department of Health ‘summary of surgical care practitioner consultation responses’ document that the regulation of advanced practitioner is being considered as part of the Foster review [Go to note 3]. We would welcome the outcome of this review prior to making further comments.

The core competencies at qualification
10. Medical practitioners have undergone the highest levels of medical education and training, which enables them to respond to the unexpected and to recognise when they have reached the limits of their expertise. Without the breadth of knowledge that doctors have, we are concerned that medical care practitioners will not always be able to diagnose illness accurately, know how to deal with the full range of problems that can occur during a patient’s treatment, know when and how such problems may interact with each other, and know when to refer. We are concerned that patients will be treated by practitioners who do not have sufficient knowledge or skills to treat them as they have not undergone the intensive medical training necessary to practise safely.

11. One of the most important characteristics of a medical practitioner is not their technical skill in a given procedure but their ability to make a decision about what is the appropriate medical response to a condition, to know how to respond to the unexpected and have a clear idea of the limits of their expertise and hence when to call on the expertise of others. We believe that it is the achievement of the appropriate level of competency that is significant and not the time spent in training. It is essential that the training is of a sufficient standard and length to provide skills for safe and effective practice.

12. We support the principle that medical care practitioners should be required to apply knowledge and skills in a patient centred way. We are concerned however that in practice medical care practitioners will not have the necessary range of knowledge, skills or training to undertake this. We believe that non medically qualified practitioners should operate within the limitations of pre-determined protocols for specific circumstances under the supervision of a doctor who will be ultimately responsible for the overall patient care. We seek assurance and independent evidence to show that all medical care practitioners are competent to provide safe and effective patient care in all instances of patient contact within their remit.

13. We believe that ensuring that the competencies and limitations of the medical care practitioner role are known by other healthcare practitioners will be important to the acceptance of medical care practitioners by the medical profession, other healthcare professionals and by patients.

Who should have access to prescribing formulary?
14. We believe that any access should be limited. Limitations should be placed on this role as non medically qualified staff will not have the depth and breadth of knowledge to understand how different drugs interact with each other and within the context of differing pathologies.

15. We believe that non medically qualified practitioners should not have access to a prescribing formulary identical to that of their supervising physician. Only practitioners who have attained the required competencies and completed a probationary period should have access to a prescribing formulary.

16. Prescribing by non medically qualified practitioners should be by clear and widely acknowledged guidelines that state prescribing should only occur where appropriate training has been undertaken, where practitioners have sufficient competency and where they are subject to review and audit.

17. Access to a prescribing formulary should be attained through proven attainment of required competencies. Training levels should be appropriate to the drugs being prescribed with similar levels of supervision and audit to that required by medical professionals. There should also be a requirement that non medically qualified practitioners who have attained access to prescribing formulary demonstrate on-going competent evidence-based prescribing and are accountable for the consequences of their prescribing.

18. Both the prescribing formulary and guidelines should be constantly reviewed on a continuing basis. We urge further consultation and a full review of non medical prescribing.

The core clinical skills which the MCP needs to demonstrate
19. The competencies that are set out suggest a broad based educational curriculum similar to that of undergraduate and postgraduate medical education. This would seem to be at variance with the intention to establish a grade different from a medically qualified practitioner. We would suggest that there should be wider consultation on this issue.

20. We would suggest that all aspects of clinical governance are addressed to ensure that medical care practitioner training incorporates intensive training on drug interactions, pharmacology and limited diagnosis and that evidence of attainment of sustained competency in these key areas be a prerequisite to attaining competency as a medical care practitioner.

21. We would also seek assurances that patient care will not be adversely affected by the extended role. Specifically we would reiterate the need for a named medical professional to be responsible for a patient’s care throughout their treatment and for the treatment of the patient to be holistic in approach not least because of the number and complexity of conditions a patient may have.

22. We are concerned that multiple ‘specialist’ practitioners who are skilled in a particular disease or condition area will affect the ‘joined-up’ care that patients receive. The break down of patient care according to disease or condition area is likely to impact upon the broad overview of patient care necessary for a holistic approach to healthy patient outcomes.

The core clinical conditions which the MCP will meet in practice and the level of competence required
23. If the purpose of medical care practitioners is to create medical care generalists, then medical care practitioner trainees will have neither sufficient time during their proposed training to gain in-depth knowledge nor the broad-based medical degree required to practise to a competent and safe standard. Medical care practitioners will therefore invariably become specialists with a limited clinical area of expertise as is the case with community matrons and health visitors for example. We would seek assurances that the role of the medical care practitioner has been fully defined.

24. We assume that not all medical care practitioners will achieve competency in and therefore undertake all the tasks listed, but that they will undertake tasks as directed by their clinical supervisor and required by the medical team. We seek assurances that the need for direction by the clinical supervisor will be stated throughout the core clinical conditions that the medical care practitioner is required to meet.

25. We note that medical care practitioners will be awarded a degree level qualification and would welcome clarification on how this will differ from medical qualifications and who will recognise these qualifications. We would ask whether this qualification will take the form of an actual degree awarded by a higher education institution, and if so, which higher education institutions have expressed an interest in participating or delivering such a programme.

Arrangements for teaching and supervision
26. We would wish to see evidence that current healthcare practitioners are able to take on, and want to take on, the clinical management responsibility for these practitioners.

27. We are concerned that lines of both professional responsibility and clinical responsibility have yet to be fully defined. Whilst a medical care practitioner will be professionally accountable to their regulatory body, we believe they should also be responsible to a supervising qualified medical practitioner, with clear management structures to support both the medical care practitioner and the supervising clinician.

28. Within the framework there are no proposals that clearly identify who will provide the training opportunities for medical care practitioners, where this will take place and how it will be funded. We believe that this must be clarified in detail before the implementation of the curriculum framework.

29. We are equally concerned that there is lack of clarity as to who will be responsible for the management, appraisal and professional development of medical care practitioners. We would welcome assurances that the level of supervision for all medical care practitioners, and all other similar roles, be the same. We recommend that supervision be defined as ‘under close supervision of a named consultant’.

30. We believe it is essential that whilst the consultant retains ultimate clinical responsibility for patients in their care, medical care practitioners should be accountable for their own practice.

31. We propose that consultants determine the clinical roles and responsibilities of medical care practitioners and reiterate that they should not undertake procedures without the presence of appropriate medical supervision. We believe that accountability and responsibility for patient care should be given further consideration; the implications for not doing so are far reaching and are likely to have serious consequences for patient care.

Methods of assessment, pre and post registration and national support structures
32. We are disappointed that continuing professional development will be the responsibility of the medical care practitioner alone. We would welcome a commitment within the curriculum framework that non medically qualified practitioner in extended roles be supported in a fully funded programme of continuing professional development.

33. There is a need to ensure that medical care practitioners, as with all other healthcare professionals, retain the required competencies of their role and adhere to the required standards set down in the curriculum.

34. There should be a requirement for all practitioners to demonstrate ongoing attainment of the required competencies set out in the curriculum framework.

35. We welcome the periodic assessment and the maintenance of registration for medical care practitioners and other practitioners in similar roles. We believe that mechanisms to assess competency and appropriate training should be in place for a medical care practitioner who fails to meet the required assessment criteria. There should however be limits set for the number of times a practitioner can retake components of the assessment where they have previously failed to meet the assessment criteria. However, there needs to be proper consultation as to who will undertake these assessments and what impact this will have on patient care.

36. Education and training for medical care practitioners must be subject to rigorous and nationally agreed quality standards and recognised qualifications and levels of competency. While we understand there may be differences between the devolved nations in the way that medical care practitioners and similar roles develop there should be mechanisms for recognising common competencies to ensure transferability of skills across the UK.

The title of the new role
37. The BMA has strong concerns about the proposed titles of the non medically qualified roles, including those referred to as ‘surgical care practitioners’, ‘anaesthesia practitioners’ and ‘medical care practitioners’. The BMA believes that such post holders should be called ‘assistants’, which makes it clear that the post holder is not medically qualified and is in line with international practice, most notably in America.

38. Moorthy et al [Go to note 4] undertook research to assess whether the proposed title of surgical care practitioner was a suitable title for a non medically qualified member of the surgical team. Patients wrongly believed that a ‘surgical care practitioner’ was medically qualified. It was concluded that the title was misleading to patients and that the title should be not be used by a non medically qualified member of a surgical team. We would seek assurances that this research be noted for the purposes of similarly titled roles.

39. We are equally concerned that patients may not be aware of the level of experience of medical care practitioners and believe that more consultation with patients and the public should be undertaken. Patients are required to give informed consent for any procedure undertaken. Patients should always be asked to give specific consent to be treated by a medical care practitioner. It should always be made clear that such practitioners are not medically qualified and patients should have the right to treatment by a medically qualified practitioner if they so wish. Patients should know when they are being treated by a doctor and when they are not.

40. We welcome the commitment made in the Department of Health ‘summary of surgical care practitioner consultation responses’ document to revisit the title of the role during regulatory discussions and request that this applied to all non medically qualified roles [Go to note 5].

References

1. Are patients happy with SCPs operating? R Moorthy, J Grainger, S Latis, A Scott, Royal College of Surgeons of England Bulletin, doi:10.1308/147363506X90763.
2. Medical Student debt tops £22,000 (BMA annual medical student finance survey show that students in the fifth year of medical school have an average debt of £20,172) BMA Press Release (19 December 2005).
3. Summary of Surgical Care Practitioner response Department of Health (13 September 2005) Gateway reference 5430. Read more here.
4. Surgical Care Practitioner – a confusing and misleading title R Moorthy, J Grainger, S Latis, A Scott, Royal College of Surgeons of England Bulletin, doi: 10.1308/147363506X90754 (published March 2006).
5. Summary of Surgical Care Practitioner response Department of Health (13 September 2005) Gateway reference 5430. Read more here.
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