Following the launch of an independent review into physician associates, Dr Ebrahim Mulla argues that the delay has shown the true colours of key decision makers’ attitudes towards GPs
Four Fridays ago, my car broke down on the M40 after overheating. When the recovery vehicle picked me up and dropped me home, my car enthusiast neighbour heard the commotion and suggested they take a look. A few minutes of investigating and some metal clanks later, they reassured me they could fix it quickly and for a fraction of the price a garage would. I was assured by his confidence and thought: what’s the worst that could happen?
More than a month later and I’m still without my car. My neighbour was unable to fix it, and in the process caused more damage. The garage now has to replace the whole engine block, and there’s no set finish date because the damage he caused was so extensive. When I’ve told people about my ordeal, they’ve responded with: ‘If you think it’s expensive to hire a professional to do the job, just wait until you hire an amateur.’ It is irritating – especially as that advice is also oh-so pertinent to our profession right now.
As GPs we use our professional expertise to avoid this sort of snowballing effect of poor decisions that then result in negative impacts on our patients. It can start small: making sure a patient knows they need to self-refer to the physiotherapy service for their lower back pain, so they are not waiting endlessly for a letter which will never come. If that is not done properly, the patient may disengage and years later end up with debilitating chronic back pain, forcing an early retirement. Or it could be something more significant: explaining to a patient that their back pain (because of other symptoms) could be bone cancer and directing them on the next steps to get to the bottom of things ASAP.
Our comprehensive training means we have the wisdom to differentiate between the small and significant and are prepared to deal with whatever is thrown at us – independently and to a high standard. GPs don’t just address healthcare needs safely – we do it productively too, seeing a majority of the patient contacts for a fraction of the NHS budget. We are the most cost-effective part of the NHS by far (reinforced by the Darzi report), with the partnership model ensuring those making the decisions are firmly grounded in the consequences of a poor patient experience in real time whilst maintaining tight financial discipline.
While the news of an independent review into physician associates is welcome, the road we took to get to this point has been something extraordinary and reflects abysmally on those in charge.
Key decision makers within DHSC, NHSE, and the GMC have demonstrated time and again that they don’t understand what we as GPs actually do for the NHS and fail to appreciate the fantastic deal everyone gets from GPs. There has been a tunnel-visioned agenda of reckless GP substitution by these bodies, supported by a steady constriction in the real-term funding available for a GPs’ labour. It’s left FTE GP numbers plummeting, which is bizarre given the abundance of underemployed and unemployed qualified GPs.
I’ve previously discussed how GP role substitution can work well – in limited, well-defined and supervised roles. But this substitution falls disastrously short when these replacement roles are autonomously seeing patients with undifferentiated problems. Even if productivity and autonomy are developed with time, the absence of proper foundations built by a medical degree is setting these roles up to be productively unsafe as the lack of depth and rigour means there will be huge knowledge gaps and unknown unknowns which patients will slip through. One year on and I’m even more convinced of the dangers for patients through my work in an Emergency Department, with an iceberg of poor patient experiences that runs far deeper than the tragic high-profile preventable deaths of Emily Chesterton, Susan Politt and others.
One would hope this review acknowledges the above, and also the circus of unnecessary and costly subsequent healthcare activity and patient harm that can quickly snowball by those acting as GP replacements with undifferentiated patients. The breadth of knowledge needed alongside the closed-door fast-paced nature of GP clinics means proper supervision to prevent this circus is restrictively time-consuming and impractical. It would make far more financial sense to just have a GP instead.
There are multiple sources of evidence for the independent review to draw upon when investigating the scope and safety of physician associates: the BMA survey; the RCGP vote; the unreleased GMC consultation; multiple coroners reports; the BBC Panorama expose; FOIs documenting widespread illegal prescribing and ordering of ionising radiation; and the list goes on. Even the AoRMC has called for a pause. Most important of all should be the views of patients at the heart of this, with bereaved families joining the astonishing two lawsuits against the GMC. I can only imagine how patients and their loved ones feel when it’s their health on the line.
You can probably tell I’m still salty at my neighbour for leaving me without my car. I’ve had this car since FY2, and I am quite attached. I keep hearing the taunts of ‘just wait until you hire an amateur’ ringing in my ears. Stop it people, I get it. I’ve learnt my lesson and the price of my recklessness.
How much longer will we have to wait for these key decision makers to reflect on their recklessness and fix this mess?
Dr Ebrahim Mulla is a GP in Leicester
There can no longer be any doubt as per this well considered article that so-called leaders better classified as ‘ ego’s ‘ occupying leadership roles within NHSE ,ICBs , GMC etc. and sometimes on occasion LMCs are simply unfit for purpose. Those leaders who do have the genuine interest in patients and Core Primary Care as the primary focus of their cause rather than status, excessive remuneration or simply the desire to prefer remote leisurely NHSE/ICB meeting attendance rather than General Practice Surgery attendance are outnumbered, and all too often succumb to the well-known echo chamber effect.
A background issue to add is that private or apparently non-profit (no profit often due to excessive remuneration) setups are often the first to jump on the increased profits to be made by substituting fully qualified doctors /GPs with cheaper alternative staff as opposed to GPs with comparatively on average higher educational and training backgrounds. This then creeps insidiously into other areas without due oversight.
As per this article, we are all for the use of alternative staff roles within any medical arena, where placed within their rightful delineated roles and those objecting the loudest i.e. those GP Partners and PCNs CDs, are the very perpetrators in my view who have not only contributed to the destruction of General Practice for their own personal gains but contributed no less to the devastation of the careers and standing of these allied health care professionals/ ARRs they disingenuously seek to support and should hang their heads in utter shame.
Those GPs who call for a radical halt ,rethink and reintroduction of this valuable group of ARR colleagues will be the ones to protect both GP and ARR roles and not those PCN CDs and GP partners who without any reasoning have irresponsibly introduced roles acting in some case far beyond their scope and should be held to account.
Unconvinced that recent products of rcgp “training” are significantly more skilled than PAs.
Patients seem a mystery to them, they have met so few.