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As doctors working and training in the NHS, we are no strangers to the challenge of adapting and thriving in an ever-changing landscape of healthcare. As reorganisations both top-down and bottom-up come and go, we remain ever at the coal face, and ever mindful of the effects that organisational changes may have on our training.
One of the more recent changes has been the expansion of a workforce that has been termed the Medical Associate Professions (MAPs for short), incorporating Physicians Associates (PA), Surgical Care Practitioners (SCP), Advanced Critical Care Practitioners (ACCP) and Physicians Assistants in Anaesthesia (PA(A)). The effects of this expansion have been most keenly seen in England in direct response to the NHS Five-Year Forward View.
In late 2018, the UK Government announced it would move to regulate in statute PAs and PA(A)s, omitting SCPs and ACCPs from this framework.
Over the last few years, the BMA has heard numerous accounts from members across the UK about their experiences of working and training alongside MAPs. We have heard that introduction of new roles in departments has at times been rushed, poorly planned and not properly scoped, and that the quality of training posts has been put at risk. Others have told us about the improvements that MAPs have brought about in their teams, allowing doctors in training to focus more on their own development as consultants of the future.
It has become clear that doctors’ experiences of working and training alongside MAPs is widely varied across the UK, and we want to understand why.
With greater understanding comes an opportunity to highlight best practice in new role development, advising training providers and employers how to retain high quality working and training experiences for all health care professionals in the NHS. It would also help us challenge the bad practice that is undeniably existent today.
This is where we need your help to give us clear understanding of how the new roles are affecting your training opportunities, progression, work patterns, rota gaps and so much more.
Where these roles have been introduced with benefit to the medical staff and service, we want to know how this has been achieved with specific mention to their interface with doctors. We also want to know what the pitfalls are and how to avoid medical training being put at risk.
We are inviting all doctors who have direct experience of working alongside MAPs to volunteer to participate in telephone interviews that will form the basis of our response and guidance to training providers and employers. If you are interested in taking part, please complete this expression of interest form.
Professionally, the skills mix porfolio was initially intended 20 years ago to address the lack of doctors , however increasing concerns have emerged about the observation that the non medical roles are being prioritized to replace medical roles either via duress( threats) or on the grounds that it's more cost effective?!
I do not know how many doctors are willing to raise their hands that they have been forced out of medical job via bullying via skill mix practitioners and a lot of us who did study medicine do this as a vocation , so I'm sure there are quite a few who work at Band 5/6 levels doing a medical job more effectively than skills mix counterparts.
there is the real issue that trainee doctors are not receiving adequate training/medical experience due to the skill mix composition of the "medical " workforce.
Alarmingly, more patients are noting they go into hospital, have a variety of" consults" and never get a bona fide medical opinion because they've never seen a a doctor?
when is medicine going back to medicine and not an episode of " Friends", " st elsewhere's" or some other TV program where people are pretending to do doctors roles? te patient is not an ausci model on stretcher. they're real people who need medical treatment, not a "culture"?
- PAs are paid more hour-for-hour than FY2s yet can do less (no prescribing, no ordering ionising radiology) and are trained less (2 years is less than 4 no matter what their first degree was)
- Pseudo-favouritism. Every surgical department I have worked in, PAs are being taken to clinics and theatres by consultant surgeons 'as part of their development'; Foundation doctors are expected to get on with ward work and have to fight to get the scraps of non-ward time & opportunities.
- Out of Hours. Most PAs can't work independently OOHs because they don't have full range skill sets (eg. prescribing) (exception being working alongside doctors where this is viable such as in A&E) as a result again Foundation doctors are carrying the vast of OOH work which is largely service provision not training.
I'm all for the Profession 'managing the change' as these new staff groups become more prevalent, but from the juniors perspective it currently feels like our seniors are largely abandoning the next generation of doctors, rather than taking the opportunities to restructure services to rejuvenate the doctor's training opportunities that have been lost as the NHS has got busier.
My experience? Paid more than doctors for less responsibilities, less hours, way less forced ooh, and oh, access to a degree of SPA time we mere medical trainees can only dream of. In short, yay great for them, but how about getting similar deals for actual doctors.
And it gets worse.
One of the Royal Medical colleges actually did a workplace census and there are decreasing numbers of consultants due to the number of MAPS sucking up all the training opportunities so for people on CCT training schemes, there is no guarantee to being an NHS consultant.
I've seen staff grade posts dismantled to redistribute to MAPS with greater loss financially to the system and the patients have less homogeneous care
"Benefiting medical staff" is actually a horrendous fraudulent myth.
I think PA’S are excellent. But I have no doubt that they have hampered my training. When working on ITU PA’s were able to do transfers all procedures etc. Like us they were trying to get their log book filled. I found that because the department had a workforce capable of lines and transfers there was less inclination to spend time ensuring the trainee doctors were capable of doing this. I feel in 6 months the amount I learned and the i exposure I had to procedures was significantly less than what it would have been had they not been part of the department.
I think PA’s are a good addition to workforce. But I often feel the PA’S do the procedures ( echo’s, lines, clinics, theatre time) and doctors end up left to do the donkey work ( prescribing and paper work etc). I have found this to particularly be the case when they are unable to prescribe.
I've worked with 3.all have been excellent. As long as the professions don't get blurred together, then they're a good way to boost a struggling nhs
The physician associate we have on our ward is excellent as she has been on the same ward for over a year and knows how things run and it certainly helps to ease the staffing pressures. That being said, there are definitely times where she has been prioritised for training opportunities (e.g. practical procedures) over doctors such as myself as she is seen as a long-term investment in the ward whereas we are only there for several months. This is understandable but also pretty frustrating. I also resent the fact that PAs get paid more than us for ultimately doing less work (no evening cover, no weekend work and no nights). I think they should be paid the same amount as an F1 until either they do further training or work out of hours.
During A&E placement in large teaching hospital; MAPs did all the front door screening, and were in resus quite a lot, and completely ran minors. us ACCS SHOs were almost permanently in Majors doing the same stuff over and over, with all the main decisions already made. Essentially clerking monkeys. Lead to difficulties getting ARCP signed off.
During Intensive care; MAPS were excellent for very inexperienced junior doctors, as were able to supervise procedures, but they also tended to go to A&E more than the SHOs for emergencies, and did almost all of the transfer work, which again, was problematic for gaining competencies.
It's pretty clear in the states and other 1st world countries. If you do not have a medical licence you should not be doing a medical job.
The MIT's get truckloads of doctors from overseas to boost vacancies.
ITS NOT SKILL MIX. Wake up. It is role extension. Safe and appropriate or foisted on you by politico management and therefore unsafe and inappropriate. Who decides? No one asked the patients?
Extreme role extension being pushed by govt as the solution thus unwillingness to train doctors.
"Physicians for the great and the good. Technicians for the great unwashed."
NHS has failed.
Sooner BMA wakes up to this and looks after members and not "NHS" the better.
John Miller FRCR FRCP
So speaking as a consultant.
There are some generalisations here.
1) Medical schools are poor quality (Higher student numbers, few doctors to teach them in the hospital, communication skills replacing science, not failing students that don't make the grade). Graduates should be asking for some of their student fees back. They are qualifying without being able to cannulate consistently, they require mandatory Trust training on sepsis and safe fluid prescribing and antibiotics!!! No wonder FYs are stressed as they are undertrained for the job.
2) Foundation years programme treats them like children and restricts what they can do. Everything clinical is seen as above an FY. Essentially they are there to do paperwork, discharges and fill the rota etc. They do not go to A&E to clerk patients. They are spoken to as "just the F1" by ward nursing staff.
3) Rotations are a major problem - they are too short - as a consultant i do not have the time to train them. Also what is the motivation of teaching basics 3-4 times every 3 months as a new set come in. I get teaching fatigue and training up a doctor well in my own time and effort does not incite reward. The same mistakes are made by junior doctors every 3 months. A MAP does not rotate and so by training them well for 6months - i see the benefit in my workload. Short rotations and lack of team structure mean that there is no feedback about cases for juniors.
4) Junior doctors are demotivated. This is no fault of theirs and is multifactorial. Especially when our MAP gets paid better, gets better respect and help from nursing staff, better rota, more SPA time, no weekends, no nights, 30% for overtime, and less responsibility. Training an ACP costs the nurse nothing. They are paid band 8a for 2 years whilst supernumerary and prescribing course 8K plus other courses. Treatment of junior doctors is horrendous because of a weak and poor trade union for the last 15years.
5) MAPs get bored with paperwork and discharges and move on to other tasks. Most MAPs work on registrar level now. There is a degree of bullying juniors into being below them. They all plan to be Consultant MAPs. Even they get paid more than consultants per hour and in total (start at 89K and within 5 years 104K) without on calls or weekends!
6) MAPs do alot of junior training however there are many misconceptions about their teaching. They teach often incorrectly and often just guidelines without any science. Propagating bad habits into the doctors.
7) Patient care is dubious. The MAPs training is narrow and not that deep. I have seen some terrible patient management and assessment and filled in serious SI's but they disappear. I am not willing to whistleblow. Alot of the harms or poor care by MAPs are prevented by luck or senior review or are untraceable as a complex patient had multiple care interventions in their inpatient pathway, poor care or missed opportunity cannot be separated out. The errors by junior doctors are different and a result of poor training in the hospital.
Saying that there is a role for MAPs especially is simple stream lined narrow spectrum work such as follow up clinics, outpatient clinics, heart failure clinics etc. There is alot of HARM to junior doctor training, opportunity and motivation.
I don't know because I have not read this article. I read only about plagiarism on college campuses baronmag.ca/.../ and that is interesting to me. Maybe I should read this article because my statement sounds stupid. Stay tuned folks!